Healthcare Provider Details

I. General information

NPI: 1801171376
Provider Name (Legal Business Name): BONNIE GRACE STANLEY M.ED.,ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BONNIE GRACE MALONE

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 N ORANGE AVE SUITE200
WINTER PARK FL
32789-4945
US

IV. Provider business mailing address

1134 W WINGED FOOT CIR
WINTER SPRINGS FL
32708-4203
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-4367
  • Fax:
Mailing address:
  • Phone: 407-365-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS996
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: