Provider Demographics
NPI:1710526637
Name:BOURNE, SHADLYN C (LPCC)
Entity Type:Individual
Prefix:
First Name:SHADLYN
Middle Name:C
Last Name:BOURNE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4007 65TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2158
Mailing Address - Country:US
Mailing Address - Phone:763-614-6393
Mailing Address - Fax:
Practice Address - Street 1:9800 SHELARD PKWY STE 325
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6453
Practice Address - Country:US
Practice Address - Phone:763-614-6393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health