MEDICARE: ANNA BONNER LCSW

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	1041C0700X	Clinical Social Worker	50093	TX

General Provider Information

NPI Number	:	1801071972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA BONNER LCSW

Provider Business Mailing Address
First Line	:	1505 HOMEDALE DR
Second Line	:	#2302
City	:	FORT WORTH
State	:	TX
Zip	:	76112-8356
Country	:	US
Telephone Number	:	817-239-2685
Fax Number	:

Provider Business Practice Location Address
First Line	:	1505 HOMEDALE DR
Second Line	:	#2302
City	:	FORT WORTH
State	:	TX
Zip	:	76112-8356
Country	:	US
Telephone Number	:	817-239-2685
Fax Number	:

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

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	01/08/2008

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