Provider Demographics
NPI:1528101219
Name:MERRITT, BONNIE LOUISE (PSYD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:LOUISE
Last Name:MERRITT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2322
Mailing Address - Country:US
Mailing Address - Phone:510-535-6200
Mailing Address - Fax:510-535-4167
Practice Address - Street 1:1501 FRUITVALE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2322
Practice Address - Country:US
Practice Address - Phone:510-535-6200
Practice Address - Fax:510-535-4167
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 103TF0200X
CAPSY21859103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5519OtherBEHAVIORAL HEALTH CARE SE
CA05-1063OtherFQHC MEDICARE PART A
CAZZZ29799ZOtherFQHC MEDICARE PART B