Provider Demographics
NPI:1548312960
Name:STUBBENDICK, BONITA E (LPC)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:E
Last Name:STUBBENDICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4200
Mailing Address - Country:US
Mailing Address - Phone:608-785-0001
Mailing Address - Fax:608-785-0002
Practice Address - Street 1:1707 MAIN ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4200
Practice Address - Country:US
Practice Address - Phone:608-785-0001
Practice Address - Fax:608-785-0002
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3245-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN130820Medicaid
MNHP66993OtherHEALTHPARTNERS
WI40931300Medicaid
WI40931300Medicaid