Provider Demographics
NPI:1538722079
Name:BOURNE, DENNIS
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:BOURNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 S DREXEL AVE APT S2A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-3719
Mailing Address - Country:US
Mailing Address - Phone:202-486-3203
Mailing Address - Fax:
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011443101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE