| Misty Bonham Llc | |
|
358 Nw 1st Ave Canby OR 97013-3533 | |
| (503) 427-8255 | |
| Not Available |
| Full Name | Misty Bonham Llc |
|---|---|
| Speciality | Social Worker |
| Location | 358 Nw 1st Ave, Canby, Oregon |
| Authorized Official Name and Position | Misty Bonham (OWNER/LCSW) |
| Authorized Official Contact | 5034278255 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Misty Bonham Llc Po Box 755 Canby OR 97013-0755 Ph: (503) 427-8255 | Misty Bonham Llc 358 Nw 1st Ave Canby OR 97013-3533 Ph: (503) 427-8255 |
| NPI Number | 1417729872 |
|---|---|
| Provider Enumeration Date | 10/27/2023 |
| Last Update Date | 10/27/2023 |
| Certification Date | 10/27/2023 |
| Medicare PECOS PAC ID | 3072956663 |
|---|---|
| Medicare Enrollment ID | O20240212000562 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1417729872 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Misty M Bonham |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1467010397 PECOS PAC ID: 4981047578 Enrollment ID: I20240212000599 |
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