Provider Demographics
NPI:1457127722
Name:BONHAM PSYCHOTHERAPY SERVICES
Entity Type:Organization
Organization Name:BONHAM PSYCHOTHERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:DARRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BONHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:218-256-0958
Mailing Address - Street 1:22991 KOLP RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-6134
Mailing Address - Country:US
Mailing Address - Phone:218-256-0958
Mailing Address - Fax:
Practice Address - Street 1:22991 KOLP RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-6134
Practice Address - Country:US
Practice Address - Phone:218-256-0958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-28
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty