Provider Demographics
NPI:1679030977
Name:BONNEVILLE, ANGELA D
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:BONNEVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 HARVEST GATE
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-4825
Mailing Address - Country:US
Mailing Address - Phone:847-409-2746
Mailing Address - Fax:
Practice Address - Street 1:800 S MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7487
Practice Address - Country:US
Practice Address - Phone:815-526-3750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490135951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical