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General NPI Number Information
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NPI Number | 1073137071
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Entity Type | Individual
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Provider Name | KIRSTEN NICOLE BONIFACIO PHD
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Gender | Female
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Dates
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Enumeration Date | 06/04/2020
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Last Update Date | 07/23/2021
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Provider Practice Location Address
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Address Line | 601 JOHN ST STE M-005
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City | KALAMAZOO
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State | MI
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Zip | 49007-5381
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Country | US
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Telephone | 269-341-6350
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Fax |
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Provider Business Mailing Address
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Address Line | 3201 PINEHURST LN
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City | GRAND BLANC
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State | MI
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Zip | 48439-2606
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Country | US
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Telephone | 231-557-7069
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 6352000204
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301018888
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License Number State | MI
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