Provider Demographics
NPI:1770615072
Name:BOURNE, KATHLEEN ANNE (PHD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:BOURNE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3036 REGENT ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2551
Mailing Address - Country:US
Mailing Address - Phone:510-295-7941
Mailing Address - Fax:
Practice Address - Street 1:3036 REGENT ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2551
Practice Address - Country:US
Practice Address - Phone:510-295-7941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT19927106H00000X
CAPSY14398103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP14398Medicare ID - Type Unspecified