Provider Demographics
NPI:1912393323
Name:LEBRON, BONAFACIA (LCSW)
Entity Type:Individual
Prefix:
First Name:BONAFACIA
Middle Name:
Last Name:LEBRON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06120-1936
Mailing Address - Country:US
Mailing Address - Phone:860-548-0101
Mailing Address - Fax:860-726-7836
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1806
Practice Address - Country:US
Practice Address - Phone:860-548-0101
Practice Address - Fax:860-726-7836
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0089621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical