Provider Demographics
NPI:1396838645
Name:BOURLAND, TINA MARIE (PLMHP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:BOURLAND
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 RAMADA RD STE 4
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-8800
Mailing Address - Country:US
Mailing Address - Phone:308-382-4274
Mailing Address - Fax:308-382-4374
Practice Address - Street 1:3221 RAMADA RD STE 4
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-8800
Practice Address - Country:US
Practice Address - Phone:308-382-4274
Practice Address - Fax:308-382-4374
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7938101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025351600Medicaid