Healthcare Provider Details

I. General information

NPI: 1285407882
Provider Name (Legal Business Name): JUSTIN JOHN BONTKE LCSW-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11530 S EMERALD RANCH LN
FORNEY TX
75126-7532
US

IV. Provider business mailing address

11530 S EMERALD RANCH LN
FORNEY TX
75126-7532
US

V. Phone/Fax

Practice location:
  • Phone: 708-665-4826
  • Fax:
Mailing address:
  • Phone: 708-665-4826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2026-0976
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09932024
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number64221
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: