Provider Demographics
NPI:1033211297
Name:KORCHAK, BONNIE (LMSW, CACII)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:KORCHAK
Suffix:
Gender:F
Credentials:LMSW, CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:30701 WOODWARD AVE
Practice Address - Street 2:#200
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0987
Practice Address - Country:US
Practice Address - Phone:248-288-9333
Practice Address - Fax:248-288-1362
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801077908104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker