Provider Demographics
NPI:1952524258
Name:BOURSIQUOT, PATRICK (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:BOURSIQUOT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 SANSBURYS WAY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-3619
Mailing Address - Country:US
Mailing Address - Phone:561-337-3647
Mailing Address - Fax:561-337-3648
Practice Address - Street 1:951 SANSBURYS WAY
Practice Address - Street 2:SUITE 206
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-3619
Practice Address - Country:US
Practice Address - Phone:561-337-3647
Practice Address - Fax:561-337-3648
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 58481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1013076454Medicare UPIN