Provider Demographics
NPI:1609990084
Name:BURG, BONNIE K (LICSW, BCD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:K
Last Name:BURG
Suffix:
Gender:F
Credentials:LICSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 SNELLING AVE N
Mailing Address - Street 2:#230
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6753
Mailing Address - Country:US
Mailing Address - Phone:651-647-4412
Mailing Address - Fax:651-642-5909
Practice Address - Street 1:91 SNELLING AVE N
Practice Address - Street 2:#230
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6753
Practice Address - Country:US
Practice Address - Phone:651-647-4412
Practice Address - Fax:651-642-5909
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical