Provider Demographics
NPI:1922669274
Name:BONHAM, LORA ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:ELIZABETH
Last Name:BONHAM
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 1:2776 W LIZZI CV
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7961
Mailing Address - Country:US
Mailing Address - Phone:801-631-9980
Mailing Address - Fax:
Practice Address - Street 1:2776 W LIZZI CV
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-7961
Practice Address - Country:US
Practice Address - Phone:801-631-9980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6838251041S0200X
UT9806232-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty