Provider Demographics
NPI:1275648453
Name:BONTJES, REBECCA ANN (MSW,LICSW)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ANN
Last Name:BONTJES
Suffix:
Gender:F
Credentials:MSW,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3054
Mailing Address - Country:US
Mailing Address - Phone:218-828-7371
Mailing Address - Fax:218-828-7390
Practice Address - Street 1:523 N 3RD ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3054
Practice Address - Country:US
Practice Address - Phone:218-828-7379
Practice Address - Fax:218-828-7390
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW9385101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN510P3B0OtherBCBS