Basic Information
| Provider Information | |||||||||
| NPI: | 1457006140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURGEAU | ||||||||
| FirstName: | CELIA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1437 CADIEUX RD | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482301233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135109276 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2022 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.