Provider Demographics
NPI:1700117561
Name:DEAROLPH, BONNIE JEAN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:JEAN
Last Name:DEAROLPH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 NICOLES LN
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-4225
Mailing Address - Country:US
Mailing Address - Phone:706-854-1600
Mailing Address - Fax:706-854-0432
Practice Address - Street 1:211 PLEASANT HOME RD
Practice Address - Street 2:SUITE B-2
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-0518
Practice Address - Country:US
Practice Address - Phone:706-854-1600
Practice Address - Fax:706-854-0432
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002382101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC002382OtherLPC STATE LICENSE NUMBER