Provider Demographics
NPI:1104958610
Name:BON-RUDIN, ELISE MAIA (EDD)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:MAIA
Last Name:BON-RUDIN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82A PONEMAH RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-3110
Mailing Address - Country:US
Mailing Address - Phone:603-672-0777
Mailing Address - Fax:603-880-6777
Practice Address - Street 1:82A PONEMAH RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031-3110
Practice Address - Country:US
Practice Address - Phone:603-880-7777
Practice Address - Fax:603-672-0777
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH446101YM0800X
MA1208106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30422613Medicaid