=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205131786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICK BOURSIQUOT LCSW INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2011
-----------------------------------------------------
Last Update Date | 01/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 951 SANSBURYS WAY SUITE 206
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-337-3647
-----------------------------------------------------
Fax | 561-337-3648
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 951 SANSBURYS WAY SUITE 206
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-337-3647
-----------------------------------------------------
Fax | 561-337-3648
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PATRICK BOURSIQUOT
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 561-337-3647
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | SW5848
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------