Provider Demographics
NPI:1366922288
Name:RUSSO, BONNIE (LCSW)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:PELOQUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4740 N STATE ROAD 7 STE 201
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5839
Mailing Address - Country:US
Mailing Address - Phone:954-486-4005
Mailing Address - Fax:
Practice Address - Street 1:7721 N MILITARY TRL STE 3-5
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-7429
Practice Address - Country:US
Practice Address - Phone:561-649-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW150961041C0700X, 171M00000X, 104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker