Individual
MS. KRYSTAL BOURGEOIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BSW, SAC-IT
Contact information
Practice address
2677 N 40TH ST, MILWAUKEE, WI 53210-2505
(414) 447-1965
(414) 447-1964
Mailing address
8801 W OKLAHOMA AVE APT 210, MILWAUKEE, WI 53227-4571
(414) 552-9244
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
16764-130
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
261QM0801X
—
WI
Enumeration date
10/05/2016
Last updated
02/16/2017
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