Basic Information
| Provider Information | |||||||||
| NPI: | 1821472770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURQUE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2015 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 10219 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 060669107 | 01 | CT | UBH-CONNECTICARE WELLMORE GRP/FACILITY | OTHER | NOT ELIGIBLE | 01 | CT | MHN TRICARE NORTH | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | D339209 | 01 | CT | VALUE OPTIONS/BEACON HEALTH STRATEGIES | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | UBH-UNITED HEALTH CARE WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH-OXFORD HEALTH FREEDOM/LIBERTY WELLMORE GRP/FACILITY | OTHER | 13671798 | 01 | CT | CAQH | OTHER | 008062581 | 05 | CT | MEDICAID | 060669107 | 01 | CT | UNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER |