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General NPI Number Information
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NPI Number | 1154586550
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Entity Type | Individual
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Provider Name | NATHANIEL BONOVITZ LCPC
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Gender | Male
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Dates
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Enumeration Date | 07/24/2008
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Last Update Date | 06/12/2023
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Provider Practice Location Address
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Address Line | 1151 E IRON EAGLE DR
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City | EAGLE
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State | ID
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Zip | 83616-6854
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Country | US
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Telephone | 484-557-5672
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Fax |
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Provider Business Mailing Address
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Address Line | 3631 OVERLAND RD
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City | BOISE
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State | ID
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Zip | 83705-6033
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Country | US
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Telephone | 208-343-0441
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Fax | 208-343-4993
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 4869
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC
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License Number State | ID
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