Provider Demographics
NPI:1629480231
Name:BONNIE SLADE PH.D. P.A.
Entity Type:Organization
Organization Name:BONNIE SLADE PH.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:321-729-0870
Mailing Address - Street 1:1555 PORT MALABAR BLVD.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32958
Mailing Address - Country:US
Mailing Address - Phone:321-729-0870
Mailing Address - Fax:321-952-2516
Practice Address - Street 1:1555 PORT MALABAR BLVD.
Practice Address - Street 2:SUITE 104
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32958
Practice Address - Country:US
Practice Address - Phone:321-729-0870
Practice Address - Fax:321-952-2516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-30
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY002036103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty