Provider Demographics
NPI:1295126720
Name:BONGO, LINDA (LADC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:BONGO
Suffix:
Gender:F
Credentials:LADC
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 173
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MN
Mailing Address - Zip Code:56312-0173
Mailing Address - Country:US
Mailing Address - Phone:320-441-9954
Mailing Address - Fax:
Practice Address - Street 1:909 BROADWAY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2793
Practice Address - Country:US
Practice Address - Phone:320-763-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304096101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)