Healthcare Provider Details

I. General information

NPI: 1881830982
Provider Name (Legal Business Name): BONNI S BISHOP PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2008
Last Update Date: 09/18/2022
Certification Date: 09/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 HARDEN BLVD
LAKELAND FL
33803-7952
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE DEPT
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1222
  • Fax: 863-603-6546
Mailing address:
  • Phone: 636-871-1008
  • Fax: 863-630-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY7847
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: