Healthcare Provider Details

I. General information

NPI: 1518180108
Provider Name (Legal Business Name): STEPHANIE BOURGEOIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/23/2020
Certification Date: 08/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 VILLAGE PLZ STE 2B
SOUTH ORANGE NJ
07079-2800
US

IV. Provider business mailing address

15 VILLAGE PLZ STE 2B
SOUTH ORANGE NJ
07079-2800
US

V. Phone/Fax

Practice location:
  • Phone: 973-275-6262
  • Fax:
Mailing address:
  • Phone: 973-275-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05195100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: