Provider Demographics
NPI:1780247999
Name:BOURKE, AMANDA KAY (BA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:BOURKE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KAY
Other - Last Name:SOUTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:808 NONIE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2018
Mailing Address - Country:US
Mailing Address - Phone:707-400-7057
Mailing Address - Fax:
Practice Address - Street 1:703 2ND ST STE 106
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6505
Practice Address - Country:US
Practice Address - Phone:866-206-2008
Practice Address - Fax:866-317-1665
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician