Healthcare Provider Details

I. General information

NPI: 1366964447
Provider Name (Legal Business Name): AMANDA MICHELLE BONUS DR.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA BLAZKIEWICZ

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date: 06/10/2022
Reactivation Date: 07/13/2022

III. Provider practice location address

521 PINE ST
GLENOLDEN PA
19036-1011
US

IV. Provider business mailing address

521 PINE ST
GLENOLDEN PA
19036-1011
US

V. Phone/Fax

Practice location:
  • Phone: 732-485-6147
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS020833
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: