Provider Demographics
NPI:1558845255
Name:AUSTIN, BONITA ACOLA (LCSW-C, LICSW)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:ACOLA
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:LCSW-C, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9913 DOLBY AVE
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9234
Mailing Address - Country:US
Mailing Address - Phone:240-485-8235
Mailing Address - Fax:
Practice Address - Street 1:4600 POWDER MILL RD
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-2675
Practice Address - Country:US
Practice Address - Phone:240-485-8235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500793911041C0700X
MD197091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty