Provider Demographics
NPI:1164510731
Name:BONNER, G. LYNN (MA MED, CEDS)
Entity Type:Individual
Prefix:MS
First Name:G.
Middle Name:LYNN
Last Name:BONNER
Suffix:
Gender:F
Credentials:MA MED, CEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W. FRANKLIN ST.
Mailing Address - Street 2:STE 117
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701
Mailing Address - Country:US
Mailing Address - Phone:520-620-1202
Mailing Address - Fax:520-620-1320
Practice Address - Street 1:325 W. FRANKLIN ST.
Practice Address - Street 2:STE 117
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701
Practice Address - Country:US
Practice Address - Phone:520-620-1202
Practice Address - Fax:520-620-1320
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCC1028101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ895419OtherACCESS NUMBER