1568839991 NPI number — AMY BONNEAU LICSW

Table of content: AMY BONNEAU LICSW (NPI 1568839991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568839991 NPI number — AMY BONNEAU LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONNEAU
Provider First Name:
AMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
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:
1568839991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 ALDER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALTHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02453-0504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-355-4054
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
59 GRENIER ST
Provider Second Line Business Practice Location Address:
BLDG 1509
Provider Business Practice Location Address City Name:
HANSCOM AFB
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
339-202-6194
Provider Business Practice Location Address Fax Number:
339-202-0121
Provider Enumeration Date:
09/02/2015

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: 104100000X , with the licence number:  219698 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 119622 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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