Provider Demographics
NPI:1649511007
Name:LEGGO, BONNIE (MSW, LCSW, CSAC)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:LEGGO
Suffix:
Gender:F
Credentials:MSW, LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1431
Mailing Address - Country:US
Mailing Address - Phone:262-646-4217
Mailing Address - Fax:
Practice Address - Street 1:2607 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1686
Practice Address - Country:US
Practice Address - Phone:262-313-8339
Practice Address - Fax:262-910-1653
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128772-121104100000X
WI15897-132101YA0400X
WI8292-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1306004999Medicaid