Provider Demographics
NPI:1326431008
Name:MARK, BONNIE (LMFT)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2549
Mailing Address - Country:US
Mailing Address - Phone:401-305-0182
Mailing Address - Fax:
Practice Address - Street 1:534 ANGELL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-305-0182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82443106H00000X
RI00189106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist