1336275064 NPI number — DESLIE BONANO, LCSW, BCD

Table of content: (NPI 1336275064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336275064 NPI number — DESLIE BONANO, LCSW, BCD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESLIE BONANO, LCSW, BCD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1336275064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
703 W CANAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PICAYUNE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39466-3918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 W CANAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PICAYUNE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39466-3918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-749-9477
Provider Business Practice Location Address Fax Number:
601-889-1265
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BONANO
Authorized Official First Name:
DESLIE
Authorized Official Middle Name:
Authorized Official Title or Position:
LCSW
Authorized Official Telephone Number:
601-749-9477

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  C6126 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00124843 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com