Provider Demographics
NPI:1861549792
Name:BOURDO, DENNIS R II (PSYD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:R
Last Name:BOURDO
Suffix:II
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 TRINITY PL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-5006
Mailing Address - Country:US
Mailing Address - Phone:574-272-9000
Mailing Address - Fax:574-272-9299
Practice Address - Street 1:1540 TRINITY PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5006
Practice Address - Country:US
Practice Address - Phone:574-272-9000
Practice Address - Fax:574-272-9299
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013489103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI205814984OtherTAX IDENTIFICATION