Healthcare Provider Details

I. General information

NPI: 1740118017
Provider Name (Legal Business Name): BOURNE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

548 N HOLLISTON AVE
PASADENA CA
91106-1204
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:
Mailing address:
  • Phone: 626-797-9196
  • Fax: 626-345-7790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

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