Provider Demographics
NPI:1790210128
Name:BOURNES, ROSHELLE
Entity type:Individual
Prefix:
First Name:ROSHELLE
Middle Name:
Last Name:BOURNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 MORGAN CIR
Mailing Address - Street 2:104
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-5149
Mailing Address - Country:US
Mailing Address - Phone:202-294-3216
Mailing Address - Fax:
Practice Address - Street 1:2065 MORGAN CIR
Practice Address - Street 2:104
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-5149
Practice Address - Country:US
Practice Address - Phone:202-294-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0105271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical