Provider Demographics
NPI:1104413004
Name:BOURGEOIS, GAY GELE' (RPSGT, CCSH, RST)
Entity type:Individual
Prefix:
First Name:GAY
Middle Name:GELE'
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:RPSGT, CCSH, RST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 GLEAUX DR
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-3200
Mailing Address - Country:US
Mailing Address - Phone:504-231-4483
Mailing Address - Fax:
Practice Address - Street 1:100 ASMA BLVD STE 205
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3842
Practice Address - Country:US
Practice Address - Phone:337-470-3477
Practice Address - Fax:337-289-5609
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-25
Last Update Date:2020-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA246Z00000X
LAPOLY.000176261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Single Specialty
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty