Provider Demographics
NPI:1114071289
Name:NUSSBAUM, BONNIE RAE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:RAE
Last Name:NUSSBAUM
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 1:3600 VELP AVE STE 4-A
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6503
Mailing Address - Country:US
Mailing Address - Phone:920-884-7445
Mailing Address - Fax:920-844-7449
Practice Address - Street 1:3600 VELP AVE STE 4-A
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6503
Practice Address - Country:US
Practice Address - Phone:920-884-7445
Practice Address - Fax:920-844-7449
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1598-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84700Medicare ID - Type Unspecified