Provider Demographics
NPI:1588800668
Name:BOURGUIGNON, CARRIE DOBBIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:DOBBIN
Last Name:BOURGUIGNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:DOBBIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:908 E ST STE C
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2851
Mailing Address - Country:US
Mailing Address - Phone:415-779-8329
Mailing Address - Fax:
Practice Address - Street 1:908 E ST STE C
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2851
Practice Address - Country:US
Practice Address - Phone:415-779-8329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CA28829103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program