Provider Demographics
NPI:1457903627
Name:BOURGEOIS, MICHELE (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4199 LONETREE CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1713
Mailing Address - Country:US
Mailing Address - Phone:303-859-8777
Mailing Address - Fax:
Practice Address - Street 1:954 NORTH ST UNIT 206
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3417
Practice Address - Country:US
Practice Address - Phone:303-859-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9925071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical