Provider Demographics
NPI:1134166762
Name:BOURNE, RUSSELL A JR (PHD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
Last Name:BOURNE
Suffix:JR
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 1:35 OCEAN DR
Mailing Address - Street 2:
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-3512
Mailing Address - Country:US
Mailing Address - Phone:561-748-2889
Mailing Address - Fax:561-748-1523
Practice Address - Street 1:1025 MILITARY TRL
Practice Address - Street 2:SUITE 113
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7040
Practice Address - Country:US
Practice Address - Phone:561-748-2889
Practice Address - Fax:561-748-1523
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5579103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54097OtherBCBS
FLG61853Medicare UPIN
FL54097Medicare ID - Type Unspecified