Healthcare Provider Details

I. General information

NPI: 1780941278
Provider Name (Legal Business Name): BONITA JOY AVERY BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E 17TH ST
IDAHO FALLS ID
83404-6375
US

IV. Provider business mailing address

2705 E 17TH ST
AMMON ID
83406-6601
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-8866
  • Fax:
Mailing address:
  • Phone: 208-346-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-5709
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: