Provider Demographics
NPI:1295713113
Name:BOURNE, LESLIE S (PHD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:S
Last Name:BOURNE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST FL ST12
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-856-0732
Mailing Address - Fax:508-425-5126
Practice Address - Street 1:5 NEPONSET ST FL STREET12
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2714
Practice Address - Country:US
Practice Address - Phone:508-856-0732
Practice Address - Fax:508-425-5126
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4993103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033725OtherCIGNA HEALTH PLAN
3690555OtherAETNA US HEALTHCARE
86903OtherCHILDRENS MEDICAL SECURIT
W05547OtherBLUE SHIELD INDEMNITY
042472266OtherPRIVATE HEALTHCARE SYSTEM
W05547OtherBLUE SHIELD HMO BLUE
042472266OtherHEALTHCARE VALUE MANAGEME
042472266OtherPACIFICARE
W05547OtherBLUE CARE ELECT
W50128OtherMEDICARE B
787395OtherMVP HEALTH CARE
042472266OtherONE HEALTH PLAN
042472266OtherTHREE RIVERS
2044402OtherFIRST HEALTH
990038OtherFALLON COMMUNITY HEALTH P