Provider Demographics
NPI:1013678218
Name:BOURNE, DYLANA
Entity Type:Individual
Prefix:MS
First Name:DYLANA
Middle Name:
Last Name:BOURNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DYLANA
Other - Middle Name:
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA
Mailing Address - Street 1:694 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3502
Mailing Address - Country:US
Mailing Address - Phone:929-318-4063
Mailing Address - Fax:
Practice Address - Street 1:694 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3502
Practice Address - Country:US
Practice Address - Phone:929-318-4063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health