=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053295204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK ALLEN BOURASSA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2025
-----------------------------------------------------
Last Update Date | 08/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1305 TOMMYDON ST
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95210-3364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-268-4096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 G ST APT 17
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95814-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-857-4451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 15046
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------