Provider Demographics
NPI:1063726826
Name:BOHNENKAMP, REBECCA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:BOHNENKAMP
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:RASMUSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:609 BRYDEN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5193
Mailing Address - Country:US
Mailing Address - Phone:208-413-6570
Mailing Address - Fax:208-413-9976
Practice Address - Street 1:609 BRYDEN AVE STE B
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5193
Practice Address - Country:US
Practice Address - Phone:208-413-6570
Practice Address - Fax:208-413-9976
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-333911041C0700X, 1041C0700X
ID333911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID83-4294531OtherIRS
IDLCSW-33391OtherCLINICAL LICENSURE