Provider Demographics
NPI:1619048824
Name:HALLETT, BONNIE EILEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:EILEEN
Last Name:HALLETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1162
Mailing Address - Country:US
Mailing Address - Phone:585-593-7781
Mailing Address - Fax:585-593-1291
Practice Address - Street 1:112 PARK AVE
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1162
Practice Address - Country:US
Practice Address - Phone:585-593-7781
Practice Address - Fax:585-593-1291
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045218-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
00054374001OtherUNIVERA INS
00152483OtherNORTH AMERICAN PREFERRED
NY71-02112027Medicaid
162167OtherVALUOPTIONS
000526101001OtherBLUE CROSSBLUE SHEILD
HB603100OtherGHI
NYCC2173Medicare ID - Type Unspecified