Provider Demographics
NPI:1487779070
Name:PEARSALL, BONITA M (ACSW LCSW)
Entity type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:M
Last Name:PEARSALL
Suffix:
Gender:F
Credentials:ACSW LCSW
Other - Prefix:MS
Other - First Name:BONITA
Other - Middle Name:M
Other - Last Name:BOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACSW
Mailing Address - Street 1:630 N LEMON ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063
Mailing Address - Country:US
Mailing Address - Phone:610-566-9114
Mailing Address - Fax:
Practice Address - Street 1:36 E FRRONT ST
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:610-566-9114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0125791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
542733OtherVALUE OPTIONS