Provider Demographics
NPI:1376751297
Name:MACDONALD, BONNIE LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:LOUISE
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BUENA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-1328
Mailing Address - Country:US
Mailing Address - Phone:617-838-1924
Mailing Address - Fax:781-631-6382
Practice Address - Street 1:40 SOUTH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-3282
Practice Address - Country:US
Practice Address - Phone:617-838-1924
Practice Address - Fax:781-631-6382
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6405103TB0200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05222Medicare UPIN