Provider Demographics
NPI:1558083428
Name:BONNER, DOMINIQUE (LPC)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 DECLARATION LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-2370
Mailing Address - Country:US
Mailing Address - Phone:757-724-5254
Mailing Address - Fax:
Practice Address - Street 1:317 DECLARATION LN
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-2370
Practice Address - Country:US
Practice Address - Phone:757-724-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011657101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor