Provider Demographics
NPI:1417968587
Name:BONTRAGER, DAWN ELAINE (LCSW , MDIV)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:ELAINE
Last Name:BONTRAGER
Suffix:
Gender:F
Credentials:LCSW , MDIV
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:ELAINE
Other - Last Name:BONTRAGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW , MDIV
Mailing Address - Street 1:203 E MISHAWAKA AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6602
Mailing Address - Country:US
Mailing Address - Phone:574-256-3699
Mailing Address - Fax:574-256-3060
Practice Address - Street 1:203 E MISHAWAKA AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6602
Practice Address - Country:US
Practice Address - Phone:574-256-3699
Practice Address - Fax:574-256-3060
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005207A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN237580EEEEOtherMEDICARE (ADMINASTAR FEDERAL)