1982154779 NPI number — MS. KRYSTAL BOURGEOIS BSW, SAC-IT

Table of content: MS. KRYSTAL BOURGEOIS BSW, SAC-IT (NPI 1982154779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982154779 NPI number — MS. KRYSTAL BOURGEOIS BSW, SAC-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURGEOIS
Provider First Name:
KRYSTAL
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BSW, SAC-IT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982154779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8801 W OKLAHOMA AVE APT 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53227-4571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-552-9244
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2677 N 40TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53210-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-447-1965
Provider Business Practice Location Address Fax Number:
414-447-1964
Provider Enumeration Date:
10/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  16764-130 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 261QM0801X , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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