Healthcare Provider Details

I. General information

NPI: 1194043471
Provider Name (Legal Business Name): THOMAS O. BONNER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9480 SW 77TH AVE
MIAMI FL
33156-7903
US

IV. Provider business mailing address

9480 SW 77TH AVE
MIAMI FL
33156-7903
US

V. Phone/Fax

Practice location:
  • Phone: 305-595-1616
  • Fax: 305-595-7272
Mailing address:
  • Phone: 305-595-1616
  • Fax: 305-595-7272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY2826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: