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General NPI Number Information
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NPI Number | 1356850960
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Entity Type | Individual
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Provider Name | COTY BOURQUE LCSW
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Gender | Male
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Dates
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Enumeration Date | 09/26/2017
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Last Update Date | 05/13/2025
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Provider Practice Location Address
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Address Line | 1911 MISSION 66 STE B
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City | VICKSBURG
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State | MS
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Zip | 39180-3762
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Country | US
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Telephone | 337-519-7797
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Fax |
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Provider Business Mailing Address
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Address Line | 1413 WILLOW ST
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City | NEW IBERIA
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State | LA
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Zip | 70560-1066
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Country | US
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Telephone | 337-519-7797
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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