Provider Demographics
NPI:1336414333
Name:BINGHAM, ALPHONSO
Entity Type:Individual
Prefix:
First Name:ALPHONSO
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 RANCHETTE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-9706
Mailing Address - Country:US
Mailing Address - Phone:318-732-5318
Mailing Address - Fax:318-732-5318
Practice Address - Street 1:350 RANCHETTE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-9706
Practice Address - Country:US
Practice Address - Phone:318-732-5318
Practice Address - Fax:318-732-5318
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMFT1033101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 101YS0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist