Provider Demographics
NPI:1457492118
Name:BONFIGLIO, ROXANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:
Last Name:BONFIGLIO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 N 16TH ST STE G
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7220 N 16TH ST STE G
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5253
Practice Address - Country:US
Practice Address - Phone:602-944-0480
Practice Address - Fax:602-944-1078
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3756103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ164405Medicaid
AZ113816Medicare ID - Type UnspecifiedGROUP
AZ113817Medicare ID - Type Unspecified