Individual
KENNETH STEPHEN BOURQUE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CDPT
Contact information
Practice address
5915 ORCHARD ST W, TACOMA, WA 98467-3824
(253) 414-7461
(253) 627-8387
Mailing address
4329 CONCORDIA LN SE, LACEY, WA 98503-2150
(360) 350-2082
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
60833994
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
60833994
WASHINGTON STATE DEPARTMENT OF HEALTH
WA
Enumeration date
04/30/2019
Last updated
04/30/2019
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