Healthcare Provider Details

I. General information

NPI: 1669578506
Provider Name (Legal Business Name): JANICE MARY BONNER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 E BROAD ST
HAZLETON PA
18201-5650
US

IV. Provider business mailing address

32 BRIDGE ST
MCADOO PA
18237-2419
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-2474
  • Fax:
Mailing address:
  • Phone: 570-929-2813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC000050
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: