Provider Demographics
NPI:1154461564
Name:BOURN, DARA (SSCOMH)
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:
Last Name:BOURN
Suffix:
Gender:F
Credentials:SSCOMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:LOT 870
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-5056
Mailing Address - Country:US
Mailing Address - Phone:318-688-6441
Mailing Address - Fax:
Practice Address - Street 1:1310 N HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6516
Practice Address - Country:US
Practice Address - Phone:318-676-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health