Healthcare Provider Details

I. General information

NPI: 1457838989
Provider Name (Legal Business Name): MICHELE NORDGREN BOURQUE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4329 CONCORDIA LANE SE
LACEY WA
98503
US

IV. Provider business mailing address

170 S LINCOLN STE 100
SPOKANE WA
99201
US

V. Phone/Fax

Practice location:
  • Phone: 360-819-9318
  • Fax:
Mailing address:
  • Phone: 360-819-9318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberMG60472487
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMG60472487
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: