Provider Demographics
NPI:1346737335
Name:WYANT-HEISLER, BONNIE JANE (CAC-AD)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:JANE
Last Name:WYANT-HEISLER
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5996
Mailing Address - Country:US
Mailing Address - Phone:443-406-3234
Mailing Address - Fax:
Practice Address - Street 1:111 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5996
Practice Address - Country:US
Practice Address - Phone:443-406-3234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDACO204101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)