Provider Demographics
NPI:1386955052
Name:DEFINE, BONNIE MARIE
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:MARIE
Last Name:DEFINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:MARIE
Other - Last Name:STROUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC, LMHC, NCC
Mailing Address - Street 1:828 VILLAGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-4097
Mailing Address - Country:US
Mailing Address - Phone:636-777-7867
Mailing Address - Fax:
Practice Address - Street 1:12795 CHESTERFIELD AIRPORT ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1423
Practice Address - Country:US
Practice Address - Phone:636-777-7867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 9030101YM0800X
MO2007029977101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health