Provider Demographics
NPI:1629536289
Name:BONNER, MARY RUTH (CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:RUTH
Last Name:BONNER
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:RUTH
Other - Last Name:O'MALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC SLP
Mailing Address - Street 1:3056 LINDSAY LN
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-7777
Mailing Address - Country:US
Mailing Address - Phone:810-434-2105
Mailing Address - Fax:
Practice Address - Street 1:3056 LINDSAY LN
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-7777
Practice Address - Country:US
Practice Address - Phone:810-434-2105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001523235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist