Provider Demographics
NPI:1265822753
Name:BONNER, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:BONNER
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 1:3870 ROSIN CT
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1620
Mailing Address - Country:US
Mailing Address - Phone:916-369-7872
Mailing Address - Fax:916-923-2813
Practice Address - Street 1:3870 ROSIN CT
Practice Address - Street 2:SUITE 130
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1620
Practice Address - Country:US
Practice Address - Phone:916-369-7872
Practice Address - Fax:916-923-2813
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XOtherMHA I, II, III