Provider Demographics
NPI:1801953443
Name:BOURGERIE, SUSAN MARIE (MA, LP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:BOURGERIE
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1409 WILLOW ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2269
Mailing Address - Country:US
Mailing Address - Phone:612-874-8608
Mailing Address - Fax:612-874-8612
Practice Address - Street 1:1409 WILLOW ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2269
Practice Address - Country:US
Practice Address - Phone:612-874-8608
Practice Address - Fax:612-874-8612
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1735103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3K152BOOtherBCBS PROVIDER NUMBER