Healthcare Provider Details

I. General information

NPI: 1457006140
Provider Name (Legal Business Name): CELIA LOUISE BOURGEAU M.S. T.L.L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 S LAPEER RD STE G
ORION MI
48360-2810
US

IV. Provider business mailing address

1891 OXFORD RD
GROSSE POINTE WOODS MI
48236-1847
US

V. Phone/Fax

Practice location:
  • Phone: 248-270-5660
  • Fax:
Mailing address:
  • Phone: 313-986-1899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number6362009665
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362009665
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: