MEDICARE: MARIE BOURNE LPC

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	101YP2500X	Professional Counselor	01569	MN

General Provider Information

NPI Number	:	1922463173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE BOURNE LPC

Provider Business Mailing Address
First Line	:	PO BOX 9859
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58106-9859
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4140 THIELMAN LN
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-7326
Country	:	US
Telephone Number	:	320-253-5930
Fax Number	:

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

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	12/15/2015

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