Provider Demographics
NPI:1023391505
Name:MORTON, BONNIE KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:KATHLEEN
Last Name:MORTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:BOSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 11818
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1818
Mailing Address - Country:US
Mailing Address - Phone:479-452-6650
Mailing Address - Fax:479-452-5847
Practice Address - Street 1:3111 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5017
Practice Address - Country:US
Practice Address - Phone:479-452-6650
Practice Address - Fax:479-452-5847
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2475-M104100000X
AR3294C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177603795Medicaid