Provider Demographics
NPI:1487938957
Name:MCIRVIN, BONNIE M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:M
Last Name:MCIRVIN
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 1:3741 S. BRIGHTON LANE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7636
Mailing Address - Country:US
Mailing Address - Phone:541-954-9174
Mailing Address - Fax:458-210-2788
Practice Address - Street 1:7096 E. SAN CRISTOBAL WAY
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-1838
Practice Address - Country:US
Practice Address - Phone:458-205-8943
Practice Address - Fax:458-210-2788
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
ORA2745101YM0800X
ORL2745101YM0800X
ORL67561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500784482Medicaid