Basic Information
| Provider Information | |||||||||
| NPI: | 1134512858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HYLTON | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LPC-INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 NW MEDICAL LOOP STE E | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974715545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419004285 | ||||||||
| FaxNumber: | 8888102993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1126 GATEWAY LOOP STE 140 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419004285 | ||||||||
| FaxNumber: | 8888102993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2015 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500688053 | 05 | OR | MEDICAID |