Provider Demographics
NPI:1962977470
Name:BONAMINIO, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BONAMINIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29566 NORTHWESTERN HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1036
Mailing Address - Country:US
Mailing Address - Phone:248-579-3119
Mailing Address - Fax:248-779-1819
Practice Address - Street 1:29566 NORTHWESTERN HWY STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1036
Practice Address - Country:US
Practice Address - Phone:248-579-3119
Practice Address - Fax:248-779-1819
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001969103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician