Provider Demographics
NPI:1336355841
Name:WEISS, BONNIE JILL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:JILL
Last Name:WEISS
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 1:140 MARINA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-2142
Mailing Address - Country:US
Mailing Address - Phone:415-924-5200
Mailing Address - Fax:415-924-5256
Practice Address - Street 1:140 MARINA VISTA AVE
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-2142
Practice Address - Country:US
Practice Address - Phone:415-924-5200
Practice Address - Fax:415-924-5256
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 236971041C0700X
NYR0188411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN19371Medicare ID - Type Unspecified