Provider Demographics
NPI:1154864536
Name:BONK, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BONK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 ARC DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-0512
Mailing Address - Country:US
Mailing Address - Phone:904-824-7249
Mailing Address - Fax:904-824-8063
Practice Address - Street 1:2101 ARC DR
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-0512
Practice Address - Country:US
Practice Address - Phone:904-824-7249
Practice Address - Fax:904-824-8063
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician