Healthcare Provider Details

I. General information

NPI: 1053430074
Provider Name (Legal Business Name): MARC L BONIN M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

14 BLUE HERRON RD
DUDLEY MA
01571-6035
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax:
Mailing address:
  • Phone: 508-943-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: