Healthcare Provider Details

I. General information

NPI: 1013912484
Provider Name (Legal Business Name): BONNIE B. WALBRAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 EDLIN DR
SAINT LOUIS MO
63122-1615
US

IV. Provider business mailing address

859 EDLIN DR
SAINT LOUIS MO
63122-1615
US

V. Phone/Fax

Practice location:
  • Phone: 314-607-8181
  • Fax: 314-822-5431
Mailing address:
  • Phone: 314-607-8181
  • Fax: 314-822-5431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number01035
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: