Healthcare Provider Details

I. General information

NPI: 1710870985
Provider Name (Legal Business Name): KATHRYN BONZO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 08/04/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 N MAIN ST STE 1B
MOSCOW ID
83843-2700
US

IV. Provider business mailing address

148 S COLE RD
BOISE ID
83709-0932
US

V. Phone/Fax

Practice location:
  • Phone: 208-683-8320
  • Fax: 208-969-8380
Mailing address:
  • Phone: 208-683-8320
  • Fax: 208-969-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1071470
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1071470
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: