Healthcare Provider Details

I. General information

NPI: 1063003135
Provider Name (Legal Business Name): DANA BOURGEOIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 JOLIE OAKS BLVD 197 JOLIE OAKS BLVD
THIBODAUX LA
70301
US

IV. Provider business mailing address

197 JOLIE OAKS BLVD
THIBODAUX LA
70301
US

V. Phone/Fax

Practice location:
  • Phone: 985-413-2076
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7260
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: