Healthcare Provider Details

I. General information

NPI: 1174994552
Provider Name (Legal Business Name): KIMBERLY BOURQUE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108A NORTH MAIN STREET
SUNDERLAND MA
01375-9502
US

IV. Provider business mailing address

28A W CENTER ST
FLORENCE MA
01062-1210
US

V. Phone/Fax

Practice location:
  • Phone: 413-665-8717
  • Fax:
Mailing address:
  • Phone: 413-320-0140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: