Provider Demographics
NPI:1104350610
Name:BONANCA, KRISTINA (LPC)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:BONANCA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 DUNES ST
Mailing Address - Street 2:APT 304
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5018
Mailing Address - Country:US
Mailing Address - Phone:540-907-9087
Mailing Address - Fax:
Practice Address - Street 1:1500 DUNES ST
Practice Address - Street 2:APT 304
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5018
Practice Address - Country:US
Practice Address - Phone:540-907-9087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006929101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health