Provider Demographics
NPI:1558821447
Name:BOURBON, CHRISTINA (MED, PLBA)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:BOURBON
Suffix:
Gender:F
Credentials:MED, PLBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11140 S TOWNE SQ STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-7830
Mailing Address - Country:US
Mailing Address - Phone:314-845-3900
Mailing Address - Fax:314-845-3901
Practice Address - Street 1:11140 S TOWNE SQ STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7830
Practice Address - Country:US
Practice Address - Phone:314-845-3900
Practice Address - Fax:314-845-3901
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019006849106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst