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General NPI Number Information
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NPI Number | 1033921069
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Entity Type | Organization
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Legal Business Name | LISA BONAHOOM LLC
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Dates
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Enumeration Date | 01/27/2025
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Last Update Date | 01/27/2025
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Provider Practice Location Address
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Address Line | 1850 W WAYZATA BLVD STE 150
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City | LONG LAKE
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State | MN
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Zip | 55356-4415
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Country | US
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Telephone | 952-240-9404
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Fax |
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Provider Business Mailing Address
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Address Line | 1830 PHEASANT DR
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City | EXCELSIOR
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State | MN
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Zip | 55331-9061
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Country | US
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Telephone | 952-240-9404
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Fax |
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Authorized Official
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Title or Position | MA, LMFT
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Name | LISA BONAHOOM
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Credential |
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Telephone | 952-240-9404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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