Provider Demographics
NPI:1134507593
Name:BONAHOOM, LISA (LMFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BONAHOOM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3529
Mailing Address - Country:US
Mailing Address - Phone:952-240-9404
Mailing Address - Fax:
Practice Address - Street 1:3525 MONTEREY DR
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5275
Practice Address - Country:US
Practice Address - Phone:952-993-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3111106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist