Provider Demographics
NPI:1326868852
Name:KOURBAGE, HAILEY
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:KOURBAGE
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 1:40 WILLARD ST STE 203
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1252
Mailing Address - Country:US
Mailing Address - Phone:617-463-9233
Mailing Address - Fax:857-284-8831
Practice Address - Street 1:40 WILLARD ST STE 203
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1252
Practice Address - Country:US
Practice Address - Phone:617-463-9233
Practice Address - Fax:857-284-8831
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA100749235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist