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NPI Code Detail

MEDICARE: DR. KATELYNN ANNE BOURASSA PHD

MEDICARE: DR. KATELYNN ANNE BOURASSA PHD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist38231TX

General Provider Information

NPI Number : 1457904815
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KATELYNN ANNE BOURASSA PHD
Provider Business Mailing Address
First Line : 719 E 23RD ST
Second Line :
City : HOUSTON
State : TX
Zip : 77008-2632
Country : US
Telephone Number : 218-390-1300
Fax Number :
Provider Business Practice Location Address
First Line : 6550 FANNIN ST STE 2509
Second Line :
City : HOUSTON
State : TX
Zip : 77030-2777
Country : US
Telephone Number : 713-206-8498
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/24/2019
Last Update Date : 06/24/2022

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