MEDICARE: DR. BONNIE FONS WILSON PHD

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	103TC1900X	Counseling Psychologist	6301006287	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	620C34660	OTHER	MI	BLUE CROSS BLUE SHIELD
2	5716466	OTHER	MI	AETNA

General Provider Information

NPI Number	:	1912917881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONNIE FONS WILSON PHD

Provider Business Mailing Address
First Line	:	415 W GRAND RIVER
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-4201
Country	:	US
Telephone Number	:	517-336-8005
Fax Number	:	517-333-8777

Provider Business Practice Location Address
First Line	:	415 W GRAND RIVER
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-4201
Country	:	US
Telephone Number	:	517-336-8005
Fax Number	:	517-333-8777

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/08/2007

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