Healthcare Provider Details

I. General information

NPI: 1104749878
Provider Name (Legal Business Name): MARIAH BONO-EDDY LLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28001 HARPER AVE
SAINT CLAIR SHORES MI
48081-1561
US

IV. Provider business mailing address

28001 HARPER AVE
SAINT CLAIR SHORES MI
48081-1561
US

V. Phone/Fax

Practice location:
  • Phone: 586-772-7180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451025102
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: