Provider Demographics
NPI:1568946655
Name:BONIN, KERRY
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:BONIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 SE MORELAND LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-8121
Mailing Address - Country:US
Mailing Address - Phone:503-380-4103
Mailing Address - Fax:
Practice Address - Street 1:234 SE 7TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1200
Practice Address - Country:US
Practice Address - Phone:503-236-8492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program