Provider Demographics
NPI:1265486153
Name:BOURKE, ANDREW B (PHD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:B
Last Name:BOURKE
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 1:17 HUBBARD AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-1823
Mailing Address - Country:US
Mailing Address - Phone:413-297-0970
Mailing Address - Fax:413-585-8210
Practice Address - Street 1:16 ARMORY ST
Practice Address - Street 2:25
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3857
Practice Address - Country:US
Practice Address - Phone:413-585-8211
Practice Address - Fax:413-585-8210
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7697103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50675Medicare PIN