Provider Demographics
NPI:1710411244
Name:BOURN, LAURA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:BOURN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:MCINTIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1459 STUART ENGALS BLVD
Mailing Address - Street 2:SUITE 204-A
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3600
Mailing Address - Country:US
Mailing Address - Phone:843-849-9913
Mailing Address - Fax:
Practice Address - Street 1:7504 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4108
Practice Address - Country:US
Practice Address - Phone:502-262-2887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4901103TC0700X
KY266047103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100707410Medicaid