Healthcare Provider Details

I. General information

NPI: 1568839991
Provider Name (Legal Business Name): AMY BONNEAU LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 GRENIER ST BLDG 1509
HANSCOM AFB MA
01730
US

IV. Provider business mailing address

44 ALDER ST
WALTHAM MA
02453-0504
US

V. Phone/Fax

Practice location:
  • Phone: 339-202-6194
  • Fax: 339-202-0121
Mailing address:
  • Phone: 802-355-4054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number219698
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119622
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: