Healthcare Provider Details

I. General information

NPI: 1245676162
Provider Name (Legal Business Name): ERNEST BONNER JR. MA, CASAC, ICADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2013
Last Update Date: 05/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 3RD AVE
NEW YORK NY
10029-6103
US

IV. Provider business mailing address

1788 AMSTERDAM AVE
NEW YORK NY
10031-3514
US

V. Phone/Fax

Practice location:
  • Phone: 646-632-3920
  • Fax:
Mailing address:
  • Phone: 646-529-0738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number13120
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: