Provider Demographics
NPI:1225272628
Name:BONACCI, SARA LEE (LISW-S)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LEE
Last Name:BONACCI
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7845 ANTONIO LN
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-7005
Mailing Address - Country:US
Mailing Address - Phone:614-582-0558
Mailing Address - Fax:614-863-2331
Practice Address - Street 1:7845 ANTONIO LN
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-7005
Practice Address - Country:US
Practice Address - Phone:614-582-0558
Practice Address - Fax:614-863-2331
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 0600148 S101Y00000X, 101YM0800X, 104100000X
OHI 0600148 - S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker