NICOLE BOURGOYNE, LGSW — NPI 1609693050 (Licensed & Credentialed Behavioral Health & Social Service Providers

CMS-1500 Box 24J / 33a • NPI

1609693050

Type 1 Individual Rendering/Ordering

HIPAA NUCC Taxonomy • CMS Code

1041C0700X (CMS 80)

Licensed & Credentialed Behavioral Health & Social Service Providers — Social Worker, Clinical

Box 32 Service Location & ZIP+4

4325 GRAND AVE, DULUTH, MN, 55807-2730

✓ 9-Digit EDI 837 ZIP+4 (55807-2730)

Practice Phone & Referral Fax

(218) 722-1497

Fax: (218) 722-6239

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1609693050 (NICOLE BOURGOYNE, LGSW) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

This practitioner does not currently appear in the CMS individual Order & Referring PECOS file (may practice in pediatrics, commercial-only networks, or hospital-employed settings).

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1609693050` (NPI-1 Individual Practitioner)
Provider / Legal Name	NICOLE BOURGOYNE, LGSW
Plain-English Specialty	Licensed & Credentialed Behavioral Health & Social Service Providers — Social Worker, Clinical NUCC Code: `1041C0700X` (Social Worker, Clinical)
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	4325 GRAND AVE, DULUTH, MN, 55807-2730
Practice Telephone / Fax	Tel: (218) 722-1497 \| Fax: (218) 722-6239
Administrative Mailing Address	2222 E 5TH ST, SUPERIOR, WI, 54880-3709
Enumeration & Last Sync	Enumerated: 2024-09-25 \| CMS Record Updated: 2024-09-25

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

4325 GRAND AVE, DULUTH, MN, 55807-2730

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Plain-English Taxonomy & CMS Crosswalk (1041C0700X)

What Does Taxonomy Code 1041C0700X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 1041C0700X translates to:
"Licensed & Credentialed Behavioral Health & Social Service Providers — Social Worker, Clinical"

CMS-1500 Medicare Specialty Crosswalk: CMS Code 80 (Licensed Clinical Social Worker)
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Social Worker, Clinical for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (NICOLE BOURGOYNE, LGSW)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`1041C0700X` — Social Worker, Clinical Plain English: Licensed & Credentialed Behavioral Health & Social Service Providers — Social Worker, Clinical	State: MN \| License: `32463` \| Primary: Yes (Primary)

Medical Billing, RCM & Hospital Credentialing Teams:

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NICOLE BOURGOYNE, LGSW (NPI #1609693050)