Healthcare Provider Details

I. General information

NPI: 1922669274
Provider Name (Legal Business Name): LORA ELIZABETH BONHAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 W LIZZI CV
SOUTH JORDAN UT
84095-7961
US

IV. Provider business mailing address

2776 W LIZZI CV
SOUTH JORDAN UT
84095-7961
US

V. Phone/Fax

Practice location:
  • Phone: 801-631-9980
  • Fax:
Mailing address:
  • Phone: 801-631-9980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9806232-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number683825
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: