Provider Demographics
NPI:1114166386
Name:BONK, MARY SHANNON (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SHANNON
Last Name:BONK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:43618 CARRADOC FARM TER
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8232
Mailing Address - Country:US
Mailing Address - Phone:571-333-3811
Mailing Address - Fax:571-333-3811
Practice Address - Street 1:43618 CARRADOC FARM TER
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8232
Practice Address - Country:US
Practice Address - Phone:571-333-3811
Practice Address - Fax:571-333-3811
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA2202001042235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist