Provider Demographics
NPI:1912917881
Name:WILSON, BONNIE FONS (PHD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:FONS
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:FONS WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:415 W GRAND RIVER
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-4201
Mailing Address - Country:US
Mailing Address - Phone:517-336-8005
Mailing Address - Fax:517-333-8777
Practice Address - Street 1:415 W GRAND RIVER
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-4201
Practice Address - Country:US
Practice Address - Phone:517-336-8005
Practice Address - Fax:517-333-8777
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006287103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI620C34660OtherBLUE CROSS BLUE SHIELD
MI5716466OtherAETNA
R83733Medicare UPIN
MI5716466OtherAETNA