Healthcare Provider Details

I. General information

NPI: 1568558559
Provider Name (Legal Business Name): BONI SIMONSON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 22ND AVE NW
MINOT ND
58703-0986
US

IV. Provider business mailing address

600 22ND AVE NW
MINOT ND
58703-0986
US

V. Phone/Fax

Practice location:
  • Phone: 701-837-6508
  • Fax: 701-858-1839
Mailing address:
  • Phone: 701-837-6508
  • Fax: 701-858-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number352-3-1-96-112
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier27087
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBCBSND
# 2
Identifier20281773958703A007
Identifier TypeOTHER
Identifier StateND
Identifier IssuerTRICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: