Healthcare Provider Details

I. General information

NPI: 1043288814
Provider Name (Legal Business Name): MICHAEL DEAN BONTRAGER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 SMITH ST
LOGANSPORT IN
46947-1576
US

IV. Provider business mailing address

1807 SMITH ST
LOGANSPORT IN
46947-1576
US

V. Phone/Fax

Practice location:
  • Phone: 574-732-1414
  • Fax: 574-732-0504
Mailing address:
  • Phone: 574-732-1414
  • Fax: 574-732-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000388A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: