MEDICARE: THERESA BOURQUIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	1041C0700X	Clinical Social Worker	078892	NY

General Provider Information

NPI Number	:	1134507494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA BOURQUIN

Provider Business Mailing Address
First Line	:	77 MAIN STREET
Second Line	:
City	:	HUDSON FALLS
State	:	NY
Zip	:	12831
Country	:	US
Telephone Number	:	518-746-1499
Fax Number	:	518-747-8806

Provider Business Practice Location Address
First Line	:	77 MAIN ST
Second Line	:
City	:	HUDSON FALLS
State	:	NY
Zip	:	12839-2213
Country	:	US
Telephone Number	:	518-746-1499
Fax Number	:	518-747-8806

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2015
Last Update Date	:	05/07/2015

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Directions to “ THERESA BOURQUIN ” Practice Location

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