Provider Demographics
NPI:1639277015
Name:BOURNE, WINSTON (LPC)
Entity Type:Individual
Prefix:MS
First Name:WINSTON
Middle Name:
Last Name:BOURNE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11457 SHOEMAKER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3418
Mailing Address - Country:US
Mailing Address - Phone:313-331-3435
Mailing Address - Fax:313-921-9247
Practice Address - Street 1:11457 SHOEMAKER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3418
Practice Address - Country:US
Practice Address - Phone:313-961-3700
Practice Address - Fax:313-961-3769
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008093101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401008093OtherSTATE LICENSE NUMBER