Provider Demographics
NPI:1902237183
Name:BONNETT, VIRGIL ERIC (SSW)
Entity type:Individual
Prefix:MR
First Name:VIRGIL
Middle Name:ERIC
Last Name:BONNETT
Suffix:
Gender:M
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 N BALD EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:ENOCH
Mailing Address - State:UT
Mailing Address - Zip Code:84721-7103
Mailing Address - Country:US
Mailing Address - Phone:435-590-8672
Mailing Address - Fax:
Practice Address - Street 1:4921 NORTH BALD EAGLE DR.
Practice Address - Street 2:
Practice Address - City:ENOCH
Practice Address - State:UT
Practice Address - Zip Code:84721
Practice Address - Country:US
Practice Address - Phone:435-590-8672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8697053-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker