Provider Demographics
NPI:1912053802
Name:BONITZ, DEBORAH A (PHD)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:A
Last Name:BONITZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 24TH AVE S
Mailing Address - Street 2:MENTAL HEALTH ANNEX ROOM 106
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-2637
Mailing Address - Country:US
Mailing Address - Phone:615-873-7408
Mailing Address - Fax:
Practice Address - Street 1:1310 24TH AVE S
Practice Address - Street 2:MENTAL HEALTH ANNEX ROOM 106
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2637
Practice Address - Country:US
Practice Address - Phone:615-873-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012381103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381870664OtherTAX ID
MI680G312080OtherBLUE CROSS BLUE SHIELD
MIDB012381OtherLICENSE
MI0G36021040Medicare PIN