Provider Demographics
NPI:1194902486
Name:BONNER, MARCI DANIELLE (MED)
Entity type:Individual
Prefix:MS
First Name:MARCI
Middle Name:DANIELLE
Last Name:BONNER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 DUDLEY STREET
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:617-989-9499
Mailing Address - Fax:617-445-2672
Practice Address - Street 1:520 DUDLEY STREET
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119
Practice Address - Country:US
Practice Address - Phone:617-989-9499
Practice Address - Fax:617-445-2672
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health