Healthcare Provider Details

I. General information

NPI: 1568372902
Provider Name (Legal Business Name): STEPHANIE NICOLE BONINFANTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8869 N COUNTY ROAD 250 E
ROACHDALE IN
46172-9496
US

IV. Provider business mailing address

4853 E MAIN ST
AVON IN
46123-9176
US

V. Phone/Fax

Practice location:
  • Phone: 888-714-1927
  • Fax:
Mailing address:
  • Phone: 610-609-6172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number99138656A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: