MEDICARE: MS. BONNIE SUSAN LEROY MS, CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1023090792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BONNIE SUSAN LEROY MS, CGC

Provider Business Mailing Address
First Line	:	6100 TINGDALE AVE
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55436-2641
Country	:	US
Telephone Number	:	612-624-7193
Fax Number	:	612-625-4490

Provider Business Practice Location Address
First Line	:	420 DELAWARE ST SE
Second Line	:	MMC 485, UNIVERSITY OF MINNESOTA
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55455-0341
Country	:	US
Telephone Number	:	612-624-7193
Fax Number	:	612-625-4490

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	07/08/2007

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