Provider Demographics
NPI:1477888303
Name:BONIFAS, MALLORY MARIE (MA, CF SLP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE
Last Name:BONIFAS
Suffix:
Gender:F
Credentials:MA, CF SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 MORGAN WIELAND LANE
Mailing Address - Street 2:APT 304
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813
Mailing Address - Country:US
Mailing Address - Phone:419-302-2878
Mailing Address - Fax:
Practice Address - Street 1:1215 E ORANGE ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5762
Practice Address - Country:US
Practice Address - Phone:863-802-3800
Practice Address - Fax:863-802-0480
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4193235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL592984541OtherGROUP TIN