Provider Demographics
NPI:1568759777
Name:BONACORSI, CHRISTINA ROSE (LPC)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ROSE
Last Name:BONACORSI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26545 AMERICAN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-6115
Mailing Address - Country:US
Mailing Address - Phone:800-395-3223
Mailing Address - Fax:
Practice Address - Street 1:26545 AMERICAN DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-6115
Practice Address - Country:US
Practice Address - Phone:800-395-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI640102524101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI750910402OtherBLUE CROSS