Healthcare Provider Details

I. General information

NPI: 1265602650
Provider Name (Legal Business Name): ELAINE-MARIE BONITATIBUS MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 MONT VERNON RD
NEW BOSTON NH
03070-3900
US

IV. Provider business mailing address

PO BOX 102
NEW BOSTON NH
03070-0102
US

V. Phone/Fax

Practice location:
  • Phone: 603-213-3630
  • Fax:
Mailing address:
  • Phone: 336-486-7971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1628
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number121080
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC0065557
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: