Healthcare Provider Details

I. General information

NPI: 1588194344
Provider Name (Legal Business Name): BOURNE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 LAKE AVE STE 212
ALTADENA CA
91001-6041
US

IV. Provider business mailing address

2235 LAKE AVE STE 212
ALTADENA CA
91001-6041
US

V. Phone/Fax

Practice location:
  • Phone: 626-797-9196
  • Fax: 626-345-7790
Mailing address:
  • Phone: 626-797-9196
  • Fax: 626-345-7790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CANDICE CLAYTON
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 626-773-2043