Provider Demographics
NPI:1093163065
Name:SEALS, BONNEKA TIFFANY (MS, NCC,LPC,CSAC)
Entity type:Individual
Prefix:MRS
First Name:BONNEKA
Middle Name:TIFFANY
Last Name:SEALS
Suffix:
Gender:F
Credentials:MS, NCC,LPC,CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 MINAKA DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5604
Mailing Address - Country:US
Mailing Address - Phone:414-828-8311
Mailing Address - Fax:
Practice Address - Street 1:3235 N 124TH ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:262-290-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6744-125101YP2500X, 101YM0800X
WI16190-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100057092Medicaid