Provider Demographics
NPI:1871798116
Name:SONNENBERG, RICHARD THOMAS (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:THOMAS
Last Name:SONNENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5023
Mailing Address - Country:US
Mailing Address - Phone:208-371-2123
Mailing Address - Fax:208-395-1948
Practice Address - Street 1:1414 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5023
Practice Address - Country:US
Practice Address - Phone:208-371-2123
Practice Address - Fax:208-395-1948
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID364103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1255434270Other282N00000X