Provider Demographics
NPI:1073137071
Name:BONIFACIO, KIRSTEN NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:NICOLE
Last Name:BONIFACIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 PINEHURST LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2606
Mailing Address - Country:US
Mailing Address - Phone:231-557-7069
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-005
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5381
Practice Address - Country:US
Practice Address - Phone:269-341-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000204390200000X
MI6301018888103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program