Provider Demographics
NPI:1417198391
Name:BONHAM, CHRISTINE R (LMFT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:R
Last Name:BONHAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 RABBIT BRUSH RD
Mailing Address - Street 2:
Mailing Address - City:PAVILLION
Mailing Address - State:WY
Mailing Address - Zip Code:82523-9530
Mailing Address - Country:US
Mailing Address - Phone:307-856-1632
Mailing Address - Fax:
Practice Address - Street 1:28 RABBIT BRUSH RD
Practice Address - Street 2:
Practice Address - City:PAVILLION
Practice Address - State:WY
Practice Address - Zip Code:82523-9530
Practice Address - Country:US
Practice Address - Phone:307-856-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19116101YP2500X
MT19101106H00000X
WYLMFT-131106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional