Provider Demographics
NPI:1982154779
Name:BOURGEOIS, KRYSTAL (BSW, SAC-IT)
Entity Type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:BSW, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 W OKLAHOMA AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4571
Mailing Address - Country:US
Mailing Address - Phone:414-552-9244
Mailing Address - Fax:
Practice Address - Street 1:2677 N 40TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2505
Practice Address - Country:US
Practice Address - Phone:414-447-1965
Practice Address - Fax:414-447-1964
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16764-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI261QM0801XMedicaid