Provider Demographics
NPI:1457904815
Name:BOURASSA, KATELYNN ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATELYNN
Middle Name:ANNE
Last Name:BOURASSA
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 1:719 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-2632
Mailing Address - Country:US
Mailing Address - Phone:218-390-1300
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST STE 2509
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2777
Practice Address - Country:US
Practice Address - Phone:713-206-8498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38231103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical