Basic Information
| Provider Information | |||||||||
| NPI: | 1972224392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURNE | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | BLAIRE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 VASSAR DR | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490014483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153129193 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6963 W KL AVE STE B | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490098043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695447720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2022 | ||||||||
| LastUpdateDate: | 09/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6851115621 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.