1487779070 NPI number — MRS. BONITA M PEARSALL ACSW LCSW

Table of content: MRS. BONITA M PEARSALL ACSW LCSW (NPI 1487779070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487779070 NPI number — MRS. BONITA M PEARSALL ACSW LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEARSALL
Provider First Name:
BONITA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ACSW LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOYER
Provider Other First Name:
BONITA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ACSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487779070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 N LEMON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-566-9114
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36 E FRRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-566-9114
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CW012579 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 542733 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".