Provider Demographics
NPI:1144368184
Name:PARKS BOURN, KIMBERLEY JAYNE (LCSWC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLEY
Middle Name:JAYNE
Last Name:PARKS BOURN
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:JAYNE
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSWC
Mailing Address - Street 1:PO BOX 1692
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014
Mailing Address - Country:US
Mailing Address - Phone:410-459-7609
Mailing Address - Fax:
Practice Address - Street 1:100 BOURBON STREET
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21014
Practice Address - Country:US
Practice Address - Phone:410-459-7609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD094991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical