Healthcare Provider Details

I. General information

NPI: 1588085096
Provider Name (Legal Business Name): BONNIE PARKER PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8864 BIG LAKE RD
CLARKSTON MI
48346-1010
US

IV. Provider business mailing address

8864 BIG LAKE RD
CLARKSTON MI
48346-1010
US

V. Phone/Fax

Practice location:
  • Phone: 248-922-9222
  • Fax: 248-922-9222
Mailing address:
  • Phone: 248-922-9222
  • Fax: 248-922-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6301013183
License Number StateMI

VIII. Authorized Official

Name: DR. BONNIE JO PARKER
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 248-922-9222