1417968587 NPI number — DAWN ELAINE BONTRAGER LCSW , MDIV

Table of content: DAWN ELAINE BONTRAGER LCSW , MDIV (NPI 1417968587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417968587 NPI number — DAWN ELAINE BONTRAGER LCSW , MDIV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONTRAGER
Provider First Name:
DAWN
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW , MDIV
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:
DAWN
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW , MDIV
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417968587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 E MISHAWAKA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISHAWAKA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46545-6602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-256-3699
Provider Business Mailing Address Fax Number:
574-256-3060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 E MISHAWAKA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545-6602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-256-3699
Provider Business Practice Location Address Fax Number:
574-256-3060
Provider Enumeration Date:
08/11/2006

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:  34005207A , 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: 237580EEEE . This is a "MEDICARE (ADMINASTAR FEDERAL)" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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