Provider Demographics
NPI:1285622530
Name:EDELBLUTE, BONNIE L (LPC)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:L
Last Name:EDELBLUTE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:BROUWER
Other - Last Name:LAUDICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1743 SYCAMORE AVE
Mailing Address - Street 2:MOHAVE MENTAL HEALTH CLINIC INC
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0927
Mailing Address - Country:US
Mailing Address - Phone:928-757-8111
Mailing Address - Fax:928-757-3256
Practice Address - Street 1:3505 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3011
Practice Address - Country:US
Practice Address - Phone:928-757-8111
Practice Address - Fax:928-757-3256
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC1531101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor