Provider Demographics
NPI:1568839991
Name:BONNEAU, AMY (LICSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BONNEAU
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 ALDER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-0504
Mailing Address - Country:US
Mailing Address - Phone:802-355-4054
Mailing Address - Fax:
Practice Address - Street 1:59 GRENIER ST
Practice Address - Street 2:BLDG 1509
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01730
Practice Address - Country:US
Practice Address - Phone:339-202-6194
Practice Address - Fax:339-202-0121
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219698104100000X
MD1196221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker