Provider Demographics
NPI:1982268553
Name:BOHNENKAMP BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:BOHNENKAMP BEHAVIORAL HEALTH LLC
Other - Org Name:BOHNENKAMP BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BOHNENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-553-3776
Mailing Address - Street 1:609 BRYDEN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5193
Mailing Address - Country:US
Mailing Address - Phone:208-553-3776
Mailing Address - Fax:
Practice Address - Street 1:609 BRYDEN AVE STE B
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5193
Practice Address - Country:US
Practice Address - Phone:208-553-3776
Practice Address - Fax:208-413-9976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW-33391OtherIDAHO BUREAU OF OCCUPATIONAL LICENSES