Provider Demographics
NPI:1104481977
Name:BONEFF, KIRA (MS)
Entity type:Individual
Prefix:
First Name:KIRA
Middle Name:
Last Name:BONEFF
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 VILLAGE GREEN BLVD APT 201
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-3622
Mailing Address - Country:US
Mailing Address - Phone:248-703-4883
Mailing Address - Fax:
Practice Address - Street 1:10524 GRAND RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-9559
Practice Address - Country:US
Practice Address - Phone:810-225-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017422103TC2200X
MI6352000211103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent