Healthcare Provider Details

I. General information

NPI: 1508405945
Provider Name (Legal Business Name): NATE BONOVITZ COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 E IRON EAGLE DR
EAGLE ID
83616-6854
US

IV. Provider business mailing address

5218 N DECATUR DR
BOISE ID
83704-2227
US

V. Phone/Fax

Practice location:
  • Phone: 484-557-5672
  • Fax:
Mailing address:
  • Phone: 484-557-5672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NATE BONOVITZ
Title or Position: OWNER
Credential:
Phone: 484-557-5672