Provider Demographics
NPI:1407329089
Name:BONIFACIO, RENEE ANN (LGPC)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:ANN
Last Name:BONIFACIO
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3115
Mailing Address - Country:US
Mailing Address - Phone:240-296-6272
Mailing Address - Fax:
Practice Address - Street 1:9301 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3115
Practice Address - Country:US
Practice Address - Phone:240-296-6272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8762101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health