Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | ||
Y | 103T00000X | Psychologist | ||
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | ||
N | 103TB0200X | Cognitive & Behavioral Psychologist |
NPI | 1235750639 |
---|---|
Provider Name | Dr. Michelle Lee Bourgeois |
First Address | Jamaica Plain, MA 02130-1722 |
Second Address | Boston, MA 02130-4817 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2020 |
Last Update Date | 27/04/2020 |