1144368184 NPI number — MS. KIMBERLEY JAYNE PARKS BOURN LCSWC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144368184 NPI number — MS. KIMBERLEY JAYNE PARKS BOURN LCSWC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARKS BOURN
Provider First Name:
KIMBERLEY
Provider Middle Name:
JAYNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSWC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PARKS
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
JAYNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSWC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144368184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1692
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEL AIR
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-459-7609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BOURBON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAVRE DE GRACE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-459-7609
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  09499 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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