Provider Demographics
NPI:1376144188
Name:THEIS, BONNIE ROSE (MS, LPCC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ROSE
Last Name:THEIS
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 21ST ST STE 232
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MN
Mailing Address - Zip Code:55055-1182
Mailing Address - Country:US
Mailing Address - Phone:651-560-0050
Mailing Address - Fax:651-925-0257
Practice Address - Street 1:24 3RD AVE NE
Practice Address - Street 2:UNIT B
Practice Address - City:OSSEO
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:651-560-0050
Practice Address - Fax:651-925-0257
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2630101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional