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General NPI Number Information
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NPI Number | 1801731492
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Entity Type | Organization
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Legal Business Name | BOURNE WELLNESS CENTER LLC
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Dates
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Enumeration Date | 04/21/2026
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Last Update Date | 04/21/2026
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Provider Practice Location Address
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Address Line | 4007 65TH AVE N
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City | BROOKLYN CENTER
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State | MN
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Zip | 55429
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Country | US
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Telephone | 763-614-6393
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Fax |
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Provider Business Mailing Address
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Address Line | 4007 65TH AVE N
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City | BROOKLYN CENTER
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State | MN
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Zip | 55429-2158
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Country | US
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Telephone | 763-614-6393
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHADLYN C BOURNE
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Credential |
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Telephone | 763-614-6393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | NULL
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