Provider Demographics
NPI:1154586550
Name:BONOVITZ, NATHANIEL (LCPC)
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:
Last Name:BONOVITZ
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3631 OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-6033
Mailing Address - Country:US
Mailing Address - Phone:208-343-0441
Mailing Address - Fax:208-343-4993
Practice Address - Street 1:1151 E IRON EAGLE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6854
Practice Address - Country:US
Practice Address - Phone:484-557-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4869101YM0800X
IDLPC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC #3820OtherLPC NUMBER