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General NPI Number Information
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NPI Number | 1114071289
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Entity Type | Individual
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Provider Name | BONNIE RAE NUSSBAUM PH.D.
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Gender | Female
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3600 VELP AVE STE 4-A
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City | GREEN BAY
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State | WI
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Zip | 54313-6503
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Country | US
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Telephone | 920-884-7445
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Fax | 920-844-7449
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Provider Business Mailing Address
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Address Line | 3600 VELP AVE STE 4-A
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City | GREEN BAY
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State | WI
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Zip | 54313-6503
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Country | US
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Telephone | 920-884-7445
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Fax | 920-844-7449
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1598-057
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License Number State | WI
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