Provider Demographics
NPI:1033921069
Name:LISA BONAHOOM LLC
Entity type:Organization
Organization Name:LISA BONAHOOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MA, LMFT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAHOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-240-9404
Mailing Address - Street 1:1830 PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-9061
Mailing Address - Country:US
Mailing Address - Phone:952-240-9404
Mailing Address - Fax:
Practice Address - Street 1:1850 W WAYZATA BLVD STE 150
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-4415
Practice Address - Country:US
Practice Address - Phone:952-240-9404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty