Provider Demographics
NPI:1407410715
Name:BONINE, LEAH LOUISE
Entity Type:Individual
Prefix:MISS
First Name:LEAH
Middle Name:LOUISE
Last Name:BONINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 UNIVERSITY AVE W STE 20
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4747
Mailing Address - Country:US
Mailing Address - Phone:612-373-9162
Mailing Address - Fax:
Practice Address - Street 1:1000 UNIVERSITY AVE W STE 20
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4747
Practice Address - Country:US
Practice Address - Phone:612-373-9162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical