Provider Demographics
NPI:1346983244
Name:HAGBOM, BONITA (ACLC)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:HAGBOM
Suffix:
Gender:F
Credentials:ACLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:ULM
Mailing Address - State:MT
Mailing Address - Zip Code:59485-0295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 295
Practice Address - Street 2:
Practice Address - City:ULM
Practice Address - State:MT
Practice Address - Zip Code:59485-0295
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61295697101YA0400X
MTBBH-ACLC-LIC-71887101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)