Provider Demographics
NPI:1477634673
Name:BOURKE, KATHRYN A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:A
Last Name:BOURKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-3714
Mailing Address - Country:US
Mailing Address - Phone:209-384-8808
Mailing Address - Fax:
Practice Address - Street 1:436 W 20TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-3714
Practice Address - Country:US
Practice Address - Phone:209-384-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16571103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL165710Medicare ID - Type Unspecified