Provider Demographics
NPI:1700833571
Name:BOURNEUF, LEO GERARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:GERARD
Last Name:BOURNEUF
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 N ARLINGTON HEIGHTS RD
Mailing Address - Street 2:SUITE 203E
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-3982
Mailing Address - Country:US
Mailing Address - Phone:847-259-8583
Mailing Address - Fax:847-259-8935
Practice Address - Street 1:1655 N ARLINGTON HEIGHTS RD
Practice Address - Street 2:SUITE 203E
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3982
Practice Address - Country:US
Practice Address - Phone:847-259-8583
Practice Address - Fax:847-259-8935
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21623169OtherBLUE CROSS BLUE SHIELD
ILL85992Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IL21623169OtherBLUE CROSS BLUE SHIELD