Provider Demographics
NPI:1285774463
Name:QUEEN, BONNIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:
Last Name:QUEEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 WELLESLEY RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2906
Mailing Address - Country:US
Mailing Address - Phone:215-247-5153
Mailing Address - Fax:215-247-0564
Practice Address - Street 1:7500 GERMANTOWN AVE
Practice Address - Street 2:NEW COVENANT CAMPUS ELDERS HALL SUITE 002A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-1600
Practice Address - Country:US
Practice Address - Phone:215-247-6516
Practice Address - Fax:215-247-0564
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACWO122831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1039316002Medicaid