Provider Demographics
NPI:1992346852
Name:BONDERUD, DERRICK HANS (RADT)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:HANS
Last Name:BONDERUD
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 BEACH COURT
Mailing Address - Street 2:
Mailing Address - City:LOTUS
Mailing Address - State:CA
Mailing Address - Zip Code:95651
Mailing Address - Country:US
Mailing Address - Phone:530-626-7383
Mailing Address - Fax:
Practice Address - Street 1:838 BEACH COURT
Practice Address - Street 2:
Practice Address - City:LOTUS
Practice Address - State:CA
Practice Address - Zip Code:95651
Practice Address - Country:US
Practice Address - Phone:530-626-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1365380919101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1365380919OtherCCAPP