Provider Demographics
NPI:1902942097
Name:BOURQUE, LORILEE (SLP)
Entity Type:Individual
Prefix:
First Name:LORILEE
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 MONTGOMERY BLVD NE
Mailing Address - Street 2:STE 215
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2579
Mailing Address - Country:US
Mailing Address - Phone:505-897-3080
Mailing Address - Fax:
Practice Address - Street 1:5701 MOJAVE ST NW
Practice Address - Street 2:MARIE M HUGHES ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-3032
Practice Address - Country:US
Practice Address - Phone:505-897-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1319235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK 6084Medicaid