Provider Demographics
NPI:1194488908
Name:WILLIAMS, BONA LISA (LMSW)
Entity type:Individual
Prefix:
First Name:BONA
Middle Name:LISA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4916
Mailing Address - Country:US
Mailing Address - Phone:208-238-9000
Mailing Address - Fax:
Practice Address - Street 1:745 W BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2000
Practice Address - Country:US
Practice Address - Phone:208-680-2143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-34255104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker