Basic Information
Provider Information | |||||||||
NPI: | 1841454352 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDERSON | ||||||||
FirstName: | BONNIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BITTLE | ||||||||
OtherFirstName: | BONNIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2087 | ||||||||
Address2: |   | ||||||||
City: | MERCED | ||||||||
State: | CA | ||||||||
PostalCode: | 953440087 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093816800 | ||||||||
FaxNumber: | 2097253883 | ||||||||
Practice Location | |||||||||
Address1: | 301 E 13TH ST | ||||||||
Address2: |   | ||||||||
City: | MERCED | ||||||||
State: | CA | ||||||||
PostalCode: | 95341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093816800 | ||||||||
FaxNumber: | 2097253906 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2008 | ||||||||
LastUpdateDate: | 05/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ASW26777 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 1041C0700X | 69922 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.