Healthcare Provider Details

I. General information

NPI: 1124548433
Provider Name (Legal Business Name): MATTHEW BOURNE MS COUNSELING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 WILLOWBROOK PKWY STE 102
INDIANAPOLIS IN
46205-1542
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 317-803-2270
  • Fax: 317-217-1769
Mailing address:
  • Phone: 765-288-1928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number88000436A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: