Healthcare Provider Details

I. General information

NPI: 1336043595
Provider Name (Legal Business Name): SAMUEL BOURNE LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S LOCUST ST STE A
SYCAMORE IL
60178-1865
US

IV. Provider business mailing address

207 PAWTUCKET AVE
ELGIN IL
60124-4318
US

V. Phone/Fax

Practice location:
  • Phone: 847-507-3583
  • Fax: 847-717-6790
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178021763
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: