Healthcare Provider Details

I. General information

NPI: 1508784257
Provider Name (Legal Business Name): MICHELLE BONIFAS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 E US HWY 36
PIQUA OH
45356-8201
US

IV. Provider business mailing address

625 PINEHURST DR
TIPP CITY OH
45371-8603
US

V. Phone/Fax

Practice location:
  • Phone: 937-773-4321
  • Fax: 937-778-4517
Mailing address:
  • Phone: 937-773-4321
  • Fax: 937-778-4517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number00458
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: