Basic Information
| Provider Information | |||||||||
| NPI: | 1124018650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURQUE | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | USA MEDDAC | ||||||||
| Address2: | 11050 MT BELVEDERE BLVD | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724025 | ||||||||
| FaxNumber: | 3157729498 | ||||||||
| Practice Location | |||||||||
| Address1: | USA MEDDAC ATTN: CREDENTIALS | ||||||||
| Address2: | 11050 MT BELVEDERE BLVD | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724025 | ||||||||
| FaxNumber: | 3157729498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 04825 | IA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.