=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184388613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOURNE INTELLIGENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2021
-----------------------------------------------------
Last Update Date | 10/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 BEVERLY AVE STE 2
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-326-8763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 BEVERLY AVE STE 2
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-326-8763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH AND LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MS. NAILAH FEMI BOURNE
-----------------------------------------------------
Credential | CCC-SLP
-----------------------------------------------------
Telephone | 917-932-3463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------