Provider Demographics
NPI:1992206056
Name:LEONARD, BONITA (CRM)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:LEONARD
Suffix:
Gender:F
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0516
Mailing Address - Country:US
Mailing Address - Phone:541-516-4087
Mailing Address - Fax:541-504-1195
Practice Address - Street 1:850 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-9628
Practice Address - Country:US
Practice Address - Phone:541-475-6575
Practice Address - Fax:541-504-1195
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-CRM-046101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)