Healthcare Provider Details

I. General information

NPI: 1457331563
Provider Name (Legal Business Name): BONNIE L EIDENS MSSA, LISW, CEAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 S BROADWAY
GENEVA OH
44041-9146
US

IV. Provider business mailing address

850 S BROADWAY
GENEVA OH
44041-9146
US

V. Phone/Fax

Practice location:
  • Phone: 440-813-5071
  • Fax: 440-992-7887
Mailing address:
  • Phone: 440-813-5071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0009169
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: