Provider Demographics
NPI:1548398100
Name:BONVILLAIN, ROBERT LAYNE (LCSW, LAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LAYNE
Last Name:BONVILLAIN
Suffix:
Gender:M
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 LINE AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4629
Mailing Address - Country:US
Mailing Address - Phone:318-422-3032
Mailing Address - Fax:
Practice Address - Street 1:1545 LINE AVE STE 170
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4629
Practice Address - Country:US
Practice Address - Phone:318-425-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA50461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical