Provider Demographics
NPI:1124084827
Name:BOURGEOIS, REBECCA BARR (LIC CLIN SOCIAL WORK)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:BARR
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:LIC CLIN SOCIAL WORK
Other - Prefix:MS
Other - First Name:BECKY
Other - Middle Name:B
Other - Last Name:BOURGEOIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:112 LAKE POWELL DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292
Mailing Address - Country:US
Mailing Address - Phone:318-396-2459
Mailing Address - Fax:
Practice Address - Street 1:901 WHITE ST
Practice Address - Street 2:RUSTON MENTAL HEALTH CENTER
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270
Practice Address - Country:US
Practice Address - Phone:318-251-4150
Practice Address - Fax:318-251-4177
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2664104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710342Medicaid
LA5C144Medicare ID - Type Unspecified