Healthcare Provider Details

I. General information

NPI: 1609513084
Provider Name (Legal Business Name): MELISSA BONNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA STANO LCSW

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARK BLVD STE 120
BOISE ID
83712-7793
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4100
  • Fax:
Mailing address:
  • Phone: 120-838-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW1305
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: