| Doctor Name: | MR. KYLE P BOURQUE |
| NPI Number: | 1124018650 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LISW |
| License Number: | 04825 |
| Business Practice Address: | Usa Meddac Attn: Credentials 11050 Mt Belvedere Blvd Fort Drum, NY - 136025004 |
| Business Phone Number: | 3157724025 |
| Business Fax Number: | 3157729498 |
| Mailing Address: | Usa Meddac Attn: Credentials, 11050 Mt Belvedere Blvd FORT DRUM |
| State: | NY |
| Postal Code: | 136025004 |
| Phone Number: | 3157724025 |
| Fax Number: | 3157729498 |
| NPI Enumeration Date: | 10/26/2005 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 04825 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |