Provider Demographics
NPI:1447621628
Name:BONNER, DEIRDRE (MS)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6046 TRAVIATA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-0477
Mailing Address - Country:US
Mailing Address - Phone:702-381-2446
Mailing Address - Fax:
Practice Address - Street 1:6046 TRAVIATA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89141-0477
Practice Address - Country:US
Practice Address - Phone:702-381-2446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2023-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV06722-LC101YA0400X
NVCP5140101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100544052Medicaid