Healthcare Provider Details

I. General information

NPI: 1255080941
Provider Name (Legal Business Name): RACHAEL ERIN BOURGET
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 RIVERSIDE DR STE 200
COLUMBUS OH
43221-2547
US

IV. Provider business mailing address

599 BOULDER DRIVE
DELAWARE OH
43015
US

V. Phone/Fax

Practice location:
  • Phone: 866-523-4268
  • Fax:
Mailing address:
  • Phone: 740-815-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: