Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | 99025239A | IN |
N | 104100000X | Social Worker | 33004882A | IN |
NPI | 1003817032 |
---|---|
Provider Name | Suzanne Jean Bonaventura-Krischke |
First Address | Crown Point, IN 46307-3278 |
Second Address | Crown Point, IN 46307-3252 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2005 |
Last Update Date | 01/04/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200514270 | (05) | IN |