Provider Demographics
NPI:1003817032
Name:BONAVENTURA-KRISCHKE, SUZANNE JEAN (MSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:JEAN
Last Name:BONAVENTURA-KRISCHKE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-3278
Mailing Address - Country:US
Mailing Address - Phone:219-663-6353
Mailing Address - Fax:219-663-6155
Practice Address - Street 1:250 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3252
Practice Address - Country:US
Practice Address - Phone:219-663-6353
Practice Address - Fax:219-663-6155
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99025239A101YM0800X
IN33004882A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200514270Medicaid