Provider Demographics
NPI:1356845424
Name:HALE, BONITA L (LICENSED SOCIAL WORK)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:L
Last Name:HALE
Suffix:
Gender:F
Credentials:LICENSED SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5760 ROSEMONT DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5028
Mailing Address - Country:US
Mailing Address - Phone:131-743-9779
Mailing Address - Fax:
Practice Address - Street 1:2840 N HIGH SCHOOL RD STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-4724
Practice Address - Country:US
Practice Address - Phone:317-986-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33008644A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN14222274Medicaid