Provider Demographics
NPI:1689187833
Name:BONTA, KIMBERLY J (LICDC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:J
Last Name:BONTA
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 TOPSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37777
Mailing Address - Country:US
Mailing Address - Phone:865-970-7747
Mailing Address - Fax:865-379-9663
Practice Address - Street 1:5003 HORIZONS DRIVE, SUITE 110
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220
Practice Address - Country:US
Practice Address - Phone:614-889-0000
Practice Address - Fax:614-846-1916
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121078101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0075958Medicaid