Provider Demographics
NPI:1114077575
Name:ROUTH, BONNIE B (LPCA)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:B
Last Name:ROUTH
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 414
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-9499
Mailing Address - Country:US
Mailing Address - Phone:618-943-3754
Mailing Address - Fax:618-943-5766
Practice Address - Street 1:RR 3 BOX 414
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-9499
Practice Address - Country:US
Practice Address - Phone:618-943-3754
Practice Address - Fax:618-943-5766
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007390101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376006178008Medicaid
IL376006178008Medicaid
IL207184Medicare PIN