Provider Demographics
NPI:1174943526
Name:BOURNE, TRACEY R (LMHC)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:R
Last Name:BOURNE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13575 58TH ST N STE 188
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3741
Mailing Address - Country:US
Mailing Address - Phone:727-314-1224
Mailing Address - Fax:
Practice Address - Street 1:13575 58TH ST N STE 188
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3741
Practice Address - Country:US
Practice Address - Phone:727-314-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18886101YP2500X
FLMH11645101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH11645OtherLICENSED MENTAL HEALTH COUNSELOR
CA18886OtherCALIFORNIA LICENSED PROFESSIONAL CLINICAL COUNSELOR