Provider Demographics
NPI:1568747608
Name:BONI, DONNA SUE (LCAS)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:SUE
Last Name:BONI
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BERMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-5400
Mailing Address - Country:US
Mailing Address - Phone:919-452-8362
Mailing Address - Fax:919-419-0505
Practice Address - Street 1:3325 DURHAM CHAPEL HILL BLVD
Practice Address - Street 2:230 C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6235
Practice Address - Country:US
Practice Address - Phone:919-338-3959
Practice Address - Fax:919-419-0505
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2014-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1904101YA0400X
NCC008061101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC611 2356Medicaid