Provider Demographics
NPI:1467863548
Name:LEWIS, BONNIE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2981 KANELL BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4008
Mailing Address - Country:US
Mailing Address - Phone:573-712-2902
Mailing Address - Fax:
Practice Address - Street 1:2981 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-712-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130355651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical