MEDICARE: DR. JANIS BOURY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	278	WV

General Provider Information

NPI Number	:	1063574713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANIS BOURY PHD

Provider Business Mailing Address
First Line	:	PO BOX 834
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26507-0834
Country	:	US
Telephone Number	:	304-296-3040
Fax Number	:

Provider Business Practice Location Address
First Line	:	644 WHITE AVE
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26507
Country	:	US
Telephone Number	:	304-296-3040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	07/16/2007

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