Provider Demographics
NPI:1972977817
Name:BONAMASE, DOMINIQUE ELYSE (COUNSELING TRAINEE)
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:ELYSE
Last Name:BONAMASE
Suffix:
Gender:F
Credentials:COUNSELING TRAINEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 BOARDMAN CANFIELD RD STE 105
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4236
Mailing Address - Country:US
Mailing Address - Phone:330-953-1964
Mailing Address - Fax:877-253-7181
Practice Address - Street 1:833 BOARDMAN CANFIELD RD STE 105
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4236
Practice Address - Country:US
Practice Address - Phone:330-953-1964
Practice Address - Fax:877-253-7181
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1500126-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health