Provider Demographics
NPI:1538526181
Name:FORTSON, BONNIE (LPC)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:FORTSON
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 1:300 PLANTATION RD APT 1
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4442
Mailing Address - Country:US
Mailing Address - Phone:985-209-5799
Mailing Address - Fax:
Practice Address - Street 1:300 PLANTATION RD APT 1
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4442
Practice Address - Country:US
Practice Address - Phone:985-209-5799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional