Provider Demographics
NPI:1043288814
Name:BONTRAGER, MICHAEL DEAN (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:BONTRAGER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1576
Mailing Address - Country:US
Mailing Address - Phone:574-732-1414
Mailing Address - Fax:574-732-0504
Practice Address - Street 1:1807 SMITH ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1576
Practice Address - Country:US
Practice Address - Phone:574-732-1414
Practice Address - Fax:574-732-0504
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000388A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical