Provider Demographics
NPI:1508183245
Name:IDSO, BONNIE MARIE (MSCCCSLP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:MARIE
Last Name:IDSO
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 S LASSEN ST
Mailing Address - Street 2:SPC #3
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-4893
Mailing Address - Country:US
Mailing Address - Phone:510-409-2032
Mailing Address - Fax:
Practice Address - Street 1:490 S LASSEN ST
Practice Address - Street 2:SPC #3
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4893
Practice Address - Country:US
Practice Address - Phone:510-409-2032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004774A235Z00000X
CASP 10561235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist