Provider Demographics
NPI:1477015485
Name:BOURBON, CHRISTINA S (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:S
Last Name:BOURBON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 S WESTLAND AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2460
Mailing Address - Country:US
Mailing Address - Phone:352-613-5509
Mailing Address - Fax:
Practice Address - Street 1:607 S WESTLAND AVE APT 10
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2460
Practice Address - Country:US
Practice Address - Phone:352-613-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16762235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist