Healthcare Provider Details

I. General information

NPI: 1568042323
Provider Name (Legal Business Name): BONNIE LYNN MCINTYRE PHD, LICSW, LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 VERMONT AVE NW
WASHINGTON DC
20005-4905
US

IV. Provider business mailing address

1090 VERMONT AVE NW
WASHINGTON DC
20005-4905
US

V. Phone/Fax

Practice location:
  • Phone: 415-360-3833
  • Fax:
Mailing address:
  • Phone: 415-360-3833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW025566
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904017359
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32694
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200002538
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: