Provider Demographics
NPI:1013346667
Name:BOMBARDIER, MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BOMBARDIER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 KENILWORTH DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2313
Mailing Address - Country:US
Mailing Address - Phone:512-694-0215
Mailing Address - Fax:
Practice Address - Street 1:660 KENILWORTH DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-2313
Practice Address - Country:US
Practice Address - Phone:410-583-5377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05349103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical