Provider Demographics
NPI:1750691259
Name:MORA, BONNIE LYNN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:LYNN
Last Name:MORA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:BONNIE
Other - Middle Name:LYNN
Other - Last Name:NORTHROP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1428 E GALVIN ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-9272
Mailing Address - Country:US
Mailing Address - Phone:602-373-9712
Mailing Address - Fax:623-224-8578
Practice Address - Street 1:1428 E GALVIN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-9272
Practice Address - Country:US
Practice Address - Phone:602-373-9712
Practice Address - Fax:623-224-8578
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW 12819104100000X
72058132104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker