Healthcare Provider Details

I. General information

NPI: 1619095304
Provider Name (Legal Business Name): HEIDI BOURG MCGOVERN MA CCC-A-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13909 FLORIDA BLVD
LIVINGSTON LA
70754-6340
US

IV. Provider business mailing address

13909 FLORIDA BLVD
LIVINGSTON LA
70754-6340
US

V. Phone/Fax

Practice location:
  • Phone: 225-686-7600
  • Fax:
Mailing address:
  • Phone: 225-505-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3934
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number3934
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: