Provider Demographics
NPI:1861095671
Name:KANITA BOURNE LICENSED CLINICAL SOCIAL WORKER INC.
Entity type:Organization
Organization Name:KANITA BOURNE LICENSED CLINICAL SOCIAL WORKER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-520-7949
Mailing Address - Street 1:2910 S ARCHIBALD AVE
Mailing Address - Street 2:SUITE A #222
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761
Mailing Address - Country:US
Mailing Address - Phone:909-520-7949
Mailing Address - Fax:
Practice Address - Street 1:10601 CIVIC CENTER DR # 100AD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3878
Practice Address - Country:US
Practice Address - Phone:909-520-7949
Practice Address - Fax:909-614-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty