Provider Demographics
NPI:1437968930
Name:BLACK, BONNIE R (SOCIAL WORKER)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2332
Mailing Address - Country:US
Mailing Address - Phone:509-758-2568
Mailing Address - Fax:
Practice Address - Street 1:1370 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2332
Practice Address - Country:US
Practice Address - Phone:509-758-2568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-31
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-33679104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker