Provider Demographics
NPI:1558638197
Name:HOLM, BONNIE KAY (LPC)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:KAY
Last Name:HOLM
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 1:408 WALNUT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5877
Mailing Address - Country:US
Mailing Address - Phone:770-845-9344
Mailing Address - Fax:
Practice Address - Street 1:10 3RD ST
Practice Address - Street 2:STE 200
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1900
Practice Address - Country:US
Practice Address - Phone:770-845-9344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006510101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134052AMedicaid