Provider Demographics
NPI:1336572981
Name:BONHAM, NICOLE RAASTAD (MA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAASTAD
Last Name:BONHAM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:RAASTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:PO BOX 9054
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:109 W WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5621
Practice Address - Country:US
Practice Address - Phone:423-232-2600
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3525101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor