Provider Demographics
NPI:1467010397
Name:BONHAM, MISTY M (LCSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:M
Last Name:BONHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 755
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-0755
Mailing Address - Country:US
Mailing Address - Phone:503-427-8255
Mailing Address - Fax:971-377-2995
Practice Address - Street 1:358 NW 1ST AVE STE 3
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3533
Practice Address - Country:US
Practice Address - Phone:503-427-8255
Practice Address - Fax:971-377-2995
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL112171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health