Provider Demographics
NPI:1174856454
Name:BONSALL, ERIN J
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:J
Last Name:BONSALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3245
Mailing Address - Country:US
Mailing Address - Phone:336-721-7683
Mailing Address - Fax:
Practice Address - Street 1:1001 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3245
Practice Address - Country:US
Practice Address - Phone:336-721-7683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NCNCLPC BOARD ELIGIBLE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health