Healthcare Provider Details

I. General information

NPI: 1528467792
Provider Name (Legal Business Name): LACEY BOURGOIN SLP-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SCHOOL ST
RANDOLPH ME
04346-5143
US

IV. Provider business mailing address

17 SCHOOL ST
RANDOLPH ME
04346-5143
US

V. Phone/Fax

Practice location:
  • Phone: 207-588-2699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBH001153
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: