Provider Demographics
NPI:1104152206
Name:BOURNE, EDMUND (PHD)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:
Last Name:BOURNE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 CURLEW WAY
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6614
Mailing Address - Country:US
Mailing Address - Phone:415-883-2370
Mailing Address - Fax:
Practice Address - Street 1:32 CURLEW WAY
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6614
Practice Address - Country:US
Practice Address - Phone:415-883-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8439103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical