Provider Demographics
NPI:1104055474
Name:BOURGUILLON, MEGAN LYNN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LYNN
Last Name:BOURGUILLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LYNN
Other - Last Name:ZIMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1046 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1116
Mailing Address - Country:US
Mailing Address - Phone:203-330-6054
Mailing Address - Fax:203-331-4716
Practice Address - Street 1:1046 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1116
Practice Address - Country:US
Practice Address - Phone:203-330-6054
Practice Address - Fax:203-331-4716
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002136101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health