Provider Demographics
NPI:1609433226
Name:BONINO, GINA M (LSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:BONINO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:BONINO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:13325 MOHLER RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:OH
Mailing Address - Zip Code:43522-9283
Mailing Address - Country:US
Mailing Address - Phone:567-202-5042
Mailing Address - Fax:
Practice Address - Street 1:1627 HENTHORNE DR STE C
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1370
Practice Address - Country:US
Practice Address - Phone:567-202-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS19035741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical