Provider Demographics
NPI:1891960142
Name:BOONENBERG, ASHLEY LYNNE (MA)
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:LYNNE
Last Name:BOONENBERG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CLUB ROAD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2599
Mailing Address - Country:US
Mailing Address - Phone:541-343-1728
Mailing Address - Fax:855-282-3544
Practice Address - Street 1:66 CLUB ROAD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2599
Practice Address - Country:US
Practice Address - Phone:541-343-1728
Practice Address - Fax:855-282-3544
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2023-09-29
Deactivation Date:2021-05-17
Deactivation Code:
Reactivation Date:2021-05-28
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
ORC7599101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health