Provider Demographics
NPI:1275558264
Name:BREIDENBACH, BONNIE AYER (MA)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:AYER
Last Name:BREIDENBACH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 KINGSBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6603
Mailing Address - Country:US
Mailing Address - Phone:586-944-8741
Mailing Address - Fax:
Practice Address - Street 1:164 KINGSBROOK AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6603
Practice Address - Country:US
Practice Address - Phone:586-944-8741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILLP6301009372103TB0200X
MICNS 6401005658101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral