Provider Demographics
NPI:1144091505
Name:BOUNTHONG, WILLIAM TIVA (LCSW)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:TIVA
Last Name:BOUNTHONG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7399 FOREST HILLS RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3974
Mailing Address - Country:US
Mailing Address - Phone:815-708-7392
Mailing Address - Fax:815-708-8248
Practice Address - Street 1:7399 FOREST HILLS RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3974
Practice Address - Country:US
Practice Address - Phone:815-708-7392
Practice Address - Fax:815-708-8248
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149025844101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health