Healthcare Provider Details

I. General information

NPI: 1427449701
Provider Name (Legal Business Name): SHARON GAY BONGE CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHARON G PENLAND

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 SW ROCKCREEK DR.
STEVENSON WA
98648-4418
US

IV. Provider business mailing address

PO BOX 1492
STEVENSON WA
98648-1492
US

V. Phone/Fax

Practice location:
  • Phone: 509-427-3850
  • Fax: 509-427-0188
Mailing address:
  • Phone: 509-427-3850
  • Fax: 509-427-0188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00005224
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: