Provider Demographics
NPI:1124377262
Name:CULBRETH, BONITA ELAINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONITA
Middle Name:ELAINE
Last Name:CULBRETH
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 1:170 BUCKHORN TRL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-6007
Mailing Address - Country:US
Mailing Address - Phone:770-355-8256
Mailing Address - Fax:
Practice Address - Street 1:145 GOVERNORS SQ STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-4861
Practice Address - Country:US
Practice Address - Phone:770-355-8256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13606101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor