Provider Demographics
NPI:1538575139
Name:BOURGE, LAUREL NICHOLSON (LMT)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:NICHOLSON
Last Name:BOURGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:NICHOLSON
Other - Last Name:MCCASLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1273
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-4273
Mailing Address - Country:US
Mailing Address - Phone:425-345-1276
Mailing Address - Fax:
Practice Address - Street 1:211 W HILL ST RM 2
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1460
Practice Address - Country:US
Practice Address - Phone:425-345-1276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60484338225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist