Healthcare Provider Details

I. General information

NPI: 1457127722
Provider Name (Legal Business Name): BONHAM PSYCHOTHERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22991 KOLP RD
GRAND RAPIDS MN
55744-6134
US

IV. Provider business mailing address

22991 KOLP RD
GRAND RAPIDS MN
55744-6134
US

V. Phone/Fax

Practice location:
  • Phone: 218-256-0958
  • Fax:
Mailing address:
  • Phone: 218-256-0958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DARRA A BONHAM
Title or Position: CLINICAL SOCIAL WORKER
Credential: MSW, LICSW
Phone: 218-256-0958