Provider Demographics
NPI:1609241470
Name:BOHNSACK, GUINNIVERE (MFT)
Entity Type:Individual
Prefix:
First Name:GUINNIVERE
Middle Name:
Last Name:BOHNSACK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 EVERGREEN DR
Mailing Address - Street 2:APT 140B
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-9790
Mailing Address - Country:US
Mailing Address - Phone:650-440-1626
Mailing Address - Fax:
Practice Address - Street 1:170 EVERGREEN DR
Practice Address - Street 2:APT 140B
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-9790
Practice Address - Country:US
Practice Address - Phone:650-440-1626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77456106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist