Provider Demographics
NPI:1275635062
Name:MARSHALL, BONNIE (MA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:MARSHALL
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 1:121 N WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3542
Mailing Address - Country:US
Mailing Address - Phone:610-574-0597
Mailing Address - Fax:
Practice Address - Street 1:121 N WAYNE AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3542
Practice Address - Country:US
Practice Address - Phone:610-574-0597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC001959101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7435476OtherAETNA
PA470829000OtherKEYSTONE
PA2321658000OtherIBC