Provider Demographics
NPI:1538354477
Name:BONUCCELLI, BRENDA (LCSW)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:BONUCCELLI
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 1:14 S AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-2910
Mailing Address - Country:US
Mailing Address - Phone:804-402-0429
Mailing Address - Fax:
Practice Address - Street 1:14 S AUBURN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-2910
Practice Address - Country:US
Practice Address - Phone:804-402-0429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040066551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA463000281Medicaid
VAQ463000281OtherMEDICARE