Provider Demographics
NPI:1336214287
Name:WEBER RICHARDSON, BONITA L
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:L
Last Name:WEBER RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BONITA
Other - Middle Name:
Other - Last Name:KITTLESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2321 STOUT RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-7003
Mailing Address - Country:US
Mailing Address - Phone:715-235-5531
Mailing Address - Fax:
Practice Address - Street 1:2321 STOUT RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7003
Practice Address - Country:US
Practice Address - Phone:715-235-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1967 125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39777700Medicaid