Provider Demographics
NPI:1255640835
Name:BONELLA, SHANE HAROLD (M COUN, LPC)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:HAROLD
Last Name:BONELLA
Suffix:
Gender:M
Credentials:M COUN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 HARBECK RD
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5605
Mailing Address - Country:US
Mailing Address - Phone:541-476-2373
Mailing Address - Fax:541-955-7444
Practice Address - Street 1:1215 SW G ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2544
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:541-955-7444
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2795101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional