Provider Demographics
NPI:1922724392
Name:BOURGEOIS, LAUREL CHRISTINE (MSSA LISW-S,LCSW)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:CHRISTINE
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:MSSA LISW-S,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E KILGORE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-0596
Mailing Address - Country:US
Mailing Address - Phone:269-202-8368
Mailing Address - Fax:269-593-5955
Practice Address - Street 1:30754 ROCKING HORSE LN
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-5096
Practice Address - Country:US
Practice Address - Phone:269-202-8368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1041C0700X
MI1041C0700X
OHI.1901949-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical