Healthcare Provider Details

I. General information

NPI: 1114141306
Provider Name (Legal Business Name): MICHELLE RENEE BOURGUET-JIO MS,CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I-40 WEST EXIT 114 TRAVEL RD 55
LAGUNA NM
87026
US

IV. Provider business mailing address

7420 TWISTED BRANCH ST NE
ALBUQUERQUE NM
87113-0002
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-9091
  • Fax:
Mailing address:
  • Phone: 505-345-1619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3427
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: