Provider Demographics
NPI:1437102985
Name:WAYLETT, BONITA S (LCSW R)
Entity Type:Individual
Prefix:MS
First Name:BONITA
Middle Name:S
Last Name:WAYLETT
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 SACANDAGA RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-3787
Mailing Address - Country:US
Mailing Address - Phone:518-762-6704
Mailing Address - Fax:
Practice Address - Street 1:57 E FULTON ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-3212
Practice Address - Country:US
Practice Address - Phone:518-773-3531
Practice Address - Fax:518-773-9103
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR053562-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP28181Medicare UPIN