Provider Demographics
NPI:1033762844
Name:BOURQUE, KELLY MARIE (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 LANES END DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-5101
Mailing Address - Country:US
Mailing Address - Phone:615-594-2830
Mailing Address - Fax:
Practice Address - Street 1:108 4TH AVE S STE 205
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-2676
Practice Address - Country:US
Practice Address - Phone:615-594-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-20
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN769101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty