MEDICARE: DR. BONNIE B. WALBRAN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TR0400X	Rehabilitation Psychologist	01035	MO

General Provider Information

NPI Number	:	1013912484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONNIE B. WALBRAN PH.D.

Provider Business Mailing Address
First Line	:	859 EDLIN DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-1615
Country	:	US
Telephone Number	:	314-607-8181
Fax Number	:	314-822-5431

Provider Business Practice Location Address
First Line	:	859 EDLIN DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-1615
Country	:	US
Telephone Number	:	314-607-8181
Fax Number	:	314-822-5431

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	07/08/2007

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