Provider Demographics
NPI:1386707024
Name:DAMRON, BONNIE LUCILLE (LCSW)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:LUCILLE
Last Name:DAMRON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 ROOSEVELT BLVD APT G2
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-3129
Mailing Address - Country:US
Mailing Address - Phone:703-538-4289
Mailing Address - Fax:
Practice Address - Street 1:600 ROOSEVELT BLVD APT G2
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-3129
Practice Address - Country:US
Practice Address - Phone:703-538-4289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040012151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904001215OtherSTATE LICENSE NUMBER
VA764257Medicare ID - Type UnspecifiedL.C.S.W.