Provider Demographics
NPI:1629218409
Name:BONNIE RAE CONDON
Entity Type:Organization
Organization Name:BONNIE RAE CONDON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARE PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-435-6726
Mailing Address - Street 1:3101 PORTAGE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE LAKE
Mailing Address - State:ME
Mailing Address - Zip Code:04768-3111
Mailing Address - Country:US
Mailing Address - Phone:207-435-6726
Mailing Address - Fax:207-435-6949
Practice Address - Street 1:3101 PORTAGE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE LAKE
Practice Address - State:ME
Practice Address - Zip Code:04768-3111
Practice Address - Country:US
Practice Address - Phone:207-435-6726
Practice Address - Fax:207-435-6949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness