Provider Demographics
NPI:1629377312
Name:BONSU, MARY L (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BONSU
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-456-7000
Mailing Address - Fax:214-456-6133
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-456-2382
Practice Address - Fax:214-456-6133
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34498103T00000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology