Healthcare Provider Details

I. General information

NPI: 1932582608
Provider Name (Legal Business Name): ANTHONY G BONITA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

IV. Provider business mailing address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

V. Phone/Fax

Practice location:
  • Phone: 616-840-8668
  • Fax: 616-840-9762
Mailing address:
  • Phone: 616-840-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015747
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: