Provider Demographics
NPI:1164817995
Name:BONACCI, MARIA THERESE (MS, LPC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:THERESE
Last Name:BONACCI
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3234 NE WASCO ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1981
Mailing Address - Country:US
Mailing Address - Phone:503-433-9153
Mailing Address - Fax:
Practice Address - Street 1:3234 NE WASCO ST UNIT A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1981
Practice Address - Country:US
Practice Address - Phone:503-433-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500709610Medicaid