1194761478 NPI number — BONITA B SCHROCK LCSW

Table of content: BONITA B SCHROCK LCSW (NPI 1194761478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194761478 NPI number — BONITA B SCHROCK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHROCK
Provider First Name:
BONITA
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BONTRAGER
Provider Other First Name:
BONITA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194761478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 LAKEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSHEN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46528-9365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-533-1234
Provider Business Mailing Address Fax Number:
574-537-2652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 OAKLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46517-1533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-533-1234
Provider Business Practice Location Address Fax Number:
574-537-2652
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34000476A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000204390 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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