Provider Demographics
NPI:1104927581
Name:BOURQUINE, REBECCA S
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:BOURQUINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2892 FAWNWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-4119
Mailing Address - Country:US
Mailing Address - Phone:229-249-0315
Mailing Address - Fax:
Practice Address - Street 1:3120 N OAK STREET EXT
Practice Address - Street 2:SUITE B
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1007
Practice Address - Country:US
Practice Address - Phone:229-333-5218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004641101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional