Provider Demographics
NPI:1346778511
Name:WALLACE, BONNIE JEAN (MED)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:FITZWILLIAM
Mailing Address - State:NH
Mailing Address - Zip Code:03447-0037
Mailing Address - Country:US
Mailing Address - Phone:603-585-9010
Mailing Address - Fax:
Practice Address - Street 1:205 SCHOOL ST.
Practice Address - Street 2:# 202
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440
Practice Address - Country:US
Practice Address - Phone:978-632-2321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health