1023090792 NPI number — MS. BONNIE SUSAN LEROY MS, CGC

Table of content: MS. BONNIE SUSAN LEROY MS, CGC (NPI 1023090792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023090792 NPI number — MS. BONNIE SUSAN LEROY MS, CGC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEROY
Provider First Name:
BONNIE
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, CGC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023090792
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:
6100 TINGDALE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55436-2641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-624-7193
Provider Business Mailing Address Fax Number:
612-625-4490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 DELAWARE ST SE
Provider Second Line Business Practice Location Address:
MMC 485, UNIVERSITY OF MINNESOTA
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455-0341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-624-7193
Provider Business Practice Location Address Fax Number:
612-625-4490
Provider Enumeration Date:
11/17/2005

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: 170300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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