Provider Demographics
NPI:1962719500
Name:D'BOURGET, SUZANNE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:D'BOURGET
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 ALLEN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3711
Mailing Address - Country:US
Mailing Address - Phone:207-874-8133
Mailing Address - Fax:
Practice Address - Street 1:196 ALLEN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3711
Practice Address - Country:US
Practice Address - Phone:207-874-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME47235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist