Healthcare Provider Details

I. General information

NPI: 1225047855
Provider Name (Legal Business Name): BONNIE V BJODSTRUP LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1220 DEWEY AVE DEWEY CENTER
WAUWATOSA WI
53213
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-454-6707
  • Fax: 414-454-6747
Mailing address:
  • Phone: 414-647-6326
  • Fax: 414-671-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2897-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: