Provider Demographics
NPI:1043652365
Name:FRAZIER-SHEWMAKER, BONITA JO ANNE (LCPC, LMFT, NCC)
Entity Type:Individual
Prefix:MS
First Name:BONITA
Middle Name:JO ANNE
Last Name:FRAZIER-SHEWMAKER
Suffix:
Gender:F
Credentials:LCPC, LMFT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 714
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-0714
Mailing Address - Country:US
Mailing Address - Phone:208-436-4911
Mailing Address - Fax:208-436-1758
Practice Address - Street 1:512 6TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1621
Practice Address - Country:US
Practice Address - Phone:208-436-4911
Practice Address - Fax:208-436-1758
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-28
Last Update Date:2013-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC 3221101YP2500X
IDLMFT 2673106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist