Provider Demographics
NPI:1699943449
Name:BOURGOINE, PRISCILLA F (MSW)
Entity type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:F
Last Name:BOURGOINE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 SIMON ST.
Mailing Address - Street 2:2A
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060
Mailing Address - Country:US
Mailing Address - Phone:603-888-4347
Mailing Address - Fax:603-577-9157
Practice Address - Street 1:39 SIMON ST
Practice Address - Street 2:2A
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3046
Practice Address - Country:US
Practice Address - Phone:603-888-4347
Practice Address - Fax:603-577-9157
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH356104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30009530Medicaid
NH1699943449OtherMEDICARE PTAN