Provider Demographics
NPI:1902968449
Name:BOURQUE, WILLIAM L (MA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-3023
Mailing Address - Country:US
Mailing Address - Phone:860-440-3133
Mailing Address - Fax:
Practice Address - Street 1:1007 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-0839
Practice Address - Country:US
Practice Address - Phone:860-456-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health