Provider Demographics
NPI:1003432766
Name:BONASSO, MADISON (LPC)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BONASSO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:MAZZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1005 WHITE WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-6119
Mailing Address - Country:US
Mailing Address - Phone:304-460-5123
Mailing Address - Fax:
Practice Address - Street 1:1005 WHITE WILLOW WAY
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-6119
Practice Address - Country:US
Practice Address - Phone:304-460-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2573101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor