Provider Demographics
NPI:1003919549
Name:BONEBRAKE, MICHAEL B (LSCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:BONEBRAKE
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N ROCK ROAD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206
Mailing Address - Country:US
Mailing Address - Phone:316-683-3841
Mailing Address - Fax:316-686-7366
Practice Address - Street 1:240 N ROCK ROAD
Practice Address - Street 2:SUITE 303
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206
Practice Address - Country:US
Practice Address - Phone:316-683-3841
Practice Address - Fax:316-686-7366
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical