Kyle P Bourque, LISW – Social Worker in Fort Drum, NY

Key facts

NPI: 1124018650
Entity type: Individual (NPI type 1)
Primary specialty: Social Worker 104100000X
License: 04825 (IA)
Practice address: USA Meddac Attn: Credentials
11050 Mt Belvedere Blvd
Fort Drum, NY 13602-5004
Phone: (315) 772-4025
Fax: (315) 772-9498
NPI assigned: Oct 26, 2005
Sex: Male
Sole proprietor: No

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No

State licenses

License	State	Type	Specialty
04825	IA	MD	Social Worker

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Social Worker	104100000X	04825	IA	Yes

Addresses

Primary practice location

USA Meddac Attn: Credentials
11050 Mt Belvedere Blvd
Fort Drum, NY 13602-5004

Mailing address

USA Meddac
11050 Mt Belvedere Blvd
Fort Drum, NY 13602
Phone (315) 772-4025

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jan 24, 2022.

{
    "created_epoch": "1130284800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1642982400000",
    "number": "1124018650",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "USA MEDDAC",
            "address_2": "11050 MT BELVEDERE BLVD",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "13602",
            "telephone_number": "315-772-4025",
            "fax_number": "315-772-9498"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "USA MEDDAC ATTN: CREDENTIALS",
            "address_2": "11050 MT BELVEDERE BLVD",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "136025004",
            "telephone_number": "315-772-4025",
            "fax_number": "315-772-9498"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOURQUE",
        "first_name": "KYLE",
        "middle_name": "P",
        "name_prefix": "Mr.",
        "credential": "LISW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-10-26",
        "last_updated": "2022-01-24",
        "certification_date": "2022-01-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "IA",
            "license": "04825",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Drum, NY

All providers in Fort Drum, NY · Social Worker in New York

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 24, 2022. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.