Healthcare Provider Details

I. General information

NPI: 1831357763
Provider Name (Legal Business Name): TINA MARIE SMITH-BONAHUE PH D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 NW 57 STREET SUITE C
GAINESVILLE FL
32605
US

IV. Provider business mailing address

2346 NW 14 PLACE
GAINESVILLE FL
32605
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-9015
  • Fax: 352-332-9941
Mailing address:
  • Phone: 352-332-9015
  • Fax: 352-332-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY5574
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: