Provider Demographics
NPI:1437145869
Name:BONNER, CHARLES W (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:BONNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15217-2210
Mailing Address - Country:US
Mailing Address - Phone:412-422-9160
Mailing Address - Fax:412-422-8180
Practice Address - Street 1:5873 FORBES AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15217-1601
Practice Address - Country:US
Practice Address - Phone:412-422-9106
Practice Address - Fax:412-422-8180
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-00719-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA015318310004Medicaid
PA111914000OtherMAGELLAN BEHAVIORALHEALTH
PA111914000OtherAETNA
PA781511OtherHIGHMARK BC/BS