Healthcare Provider Details

I. General information

NPI: 1306352927
Provider Name (Legal Business Name): BONNIE K CETLINSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31581 GRATIOT AVE
ROSEVILLE MI
48066-4528
US

IV. Provider business mailing address

31581 GRATIOT AVE
ROSEVILLE MI
48066-4528
US

V. Phone/Fax

Practice location:
  • Phone: 586-783-4802
  • Fax: 586-218-6602
Mailing address:
  • Phone: 586-783-4802
  • Fax: 586-218-6602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401015300
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: