Provider Demographics
NPI:1427390590
Name:BONICH, DANIELLE R (LCSW)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:R
Last Name:BONICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4131 HIGH COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4265
Mailing Address - Country:US
Mailing Address - Phone:678-656-8249
Mailing Address - Fax:
Practice Address - Street 1:5357 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-5027
Practice Address - Country:US
Practice Address - Phone:770-942-4742
Practice Address - Fax:770-293-0786
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0047891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97924545OtherBLUE CROSS BLUE SHIELD
GA2028016137OtherMEDICARE PTAN
GA4829878OtherCIGNA
GA81-3033255OtherREVIVAL COUNSELING SERVICES