Healthcare Provider Details

I. General information

NPI: 1801731492
Provider Name (Legal Business Name): BOURNE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4007 65TH AVE N
BROOKLYN CENTER MN
55429
US

IV. Provider business mailing address

4007 65TH AVE N
BROOKLYN CENTER MN
55429-2158
US

V. Phone/Fax

Practice location:
  • Phone: 763-614-6393
  • Fax:
Mailing address:
  • Phone: 763-614-6393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHADLYN C BOURNE
Title or Position: OWNER
Credential:
Phone: 763-614-6393