Provider Demographics
NPI:1518106376
Name:DANIELSON, BONNIE MAE (MA, PPC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:MAE
Last Name:DANIELSON
Suffix:
Gender:F
Credentials:MA, PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1171
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-1171
Mailing Address - Country:US
Mailing Address - Phone:209-754-3023
Mailing Address - Fax:
Practice Address - Street 1:3393 CENTRAL HILL RD.
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-754-3023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 2797106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC2797OtherJMFT CALIFORNIA STATE LICENSE