Provider Demographics
NPI:1316012537
Name:BOURBON, MICHAEL R (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BOURBON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 LAKEVIEW PKWY
Mailing Address - Street 2:# 155
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1400
Mailing Address - Country:US
Mailing Address - Phone:847-918-0129
Mailing Address - Fax:847-918-0747
Practice Address - Street 1:977 LAKEVIEW PKWY
Practice Address - Street 2:# 155
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1400
Practice Address - Country:US
Practice Address - Phone:847-918-0129
Practice Address - Fax:847-918-0747
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490070841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1632567OtherBCBS
IL1632567OtherBCBS
IL208146Medicare ID - Type Unspecified