Healthcare Provider Details

I. General information

NPI: 1306444872
Provider Name (Legal Business Name): MELISSA BOURGOIN MA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 RIVERWOOD DR
PEMBROKE NH
03275-3701
US

IV. Provider business mailing address

806 N MAIN ST
LACONIA NH
03246-2603
US

V. Phone/Fax

Practice location:
  • Phone: 603-225-2715
  • Fax:
Mailing address:
  • Phone: 603-524-9090
  • Fax: 603-524-1497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0736
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: