MEDICARE: HEATHER JO BONITZ-MOORE ATR-BC, LPC, IMH-E

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	101YP2500X	Professional Counselor	001445	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821165788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER JO BONITZ-MOORE ATR-BC, LPC, IMH-E

Provider Business Mailing Address
First Line	:	195 FOWLER RD
Second Line	:
City	:	LEBANON
State	:	CT
Zip	:	06249-2503
Country	:	US
Telephone Number	:	860-617-4082
Fax Number	:

Provider Business Practice Location Address
First Line	:	46 LEBANON RD
Second Line	:
City	:	BOZRAH
State	:	CT
Zip	:	06334-1116
Country	:	US
Telephone Number	:	860-617-4082
Fax Number	:	860-617-4082

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	03/17/2018

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