Provider Demographics
NPI:1720898349
Name:BOURQUE, CAROLYNN M (LCSW)
Entity type:Individual
Prefix:
First Name:CAROLYNN
Middle Name:M
Last Name:BOURQUE
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 1:75369 HIGHWAY 1083
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435-6569
Mailing Address - Country:US
Mailing Address - Phone:985-630-6929
Mailing Address - Fax:
Practice Address - Street 1:75369 HIGHWAY 1083
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70435-6569
Practice Address - Country:US
Practice Address - Phone:985-630-6929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA75941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical