Basic Information
| Provider Information | |||||||||
| NPI: | 1679695167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURGEAULT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | BA, CASAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189263207 | ||||||||
| FaxNumber: | 5189263215 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 HARLEM ST | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128012934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189267200 | ||||||||
| FaxNumber: | 5189267036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 4976 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.