Provider Demographics
NPI:1538652227
Name:BONAVENTURE, FABIENNE (COTA)
Entity Type:Individual
Prefix:
First Name:FABIENNE
Middle Name:
Last Name:BONAVENTURE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13014 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3661
Mailing Address - Country:US
Mailing Address - Phone:301-543-0960
Mailing Address - Fax:
Practice Address - Street 1:13014 5TH ST
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720
Practice Address - Country:US
Practice Address - Phone:301-543-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOTA100000305101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTA100000305OtherN/A