Provider Demographics
NPI:1235982224
Name:BOURNE, CLARISSA BARBARA (BT)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:BARBARA
Last Name:BOURNE
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:B
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BT
Mailing Address - Street 1:801 CORPORATE CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2627
Mailing Address - Country:US
Mailing Address - Phone:909-618-0974
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2627
Practice Address - Country:US
Practice Address - Phone:909-618-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician