Provider Demographics
NPI:1205655180
Name:GOULBOURNE, BLONDENE PATRICE (LAC)
Entity type:Individual
Prefix:
First Name:BLONDENE
Middle Name:PATRICE
Last Name:GOULBOURNE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 GARIBALDI AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-1806
Mailing Address - Country:US
Mailing Address - Phone:718-208-3959
Mailing Address - Fax:
Practice Address - Street 1:1053 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-3607
Practice Address - Country:US
Practice Address - Phone:718-208-3959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00767200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health