MEDICARE: MARY M. BOURN LCSW

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
1	1041C0700X	Clinical Social Worker	398	CO

General Provider Information

NPI Number	:	1649262601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY M. BOURN LCSW

Provider Business Mailing Address
First Line	:	1650 COCHRANE CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80913-4613
Country	:	US
Telephone Number	:	719-526-9826
Fax Number	:	719-526-9126

Provider Business Practice Location Address
First Line	:	1665 COCHRANE CIR BLDG RM121
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4603
Country	:	US
Telephone Number	:	719-526-9826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	02/19/2025

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