=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811154446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONNIE ANDERSEN ENGEL PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2008
-----------------------------------------------------
Last Update Date | 01/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 W NEW YORK AVENUE SUITE 1
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-943-9443
-----------------------------------------------------
Fax | 386-943-9883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 W NEW YORK AVENUE SUITE 1
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-943-9443
-----------------------------------------------------
Fax | 386-943-9883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY2178
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------