Provider Demographics
NPI:1639320534
Name:SCHAMBACK, BONNIE KEELING (MA PA)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:KEELING
Last Name:SCHAMBACK
Suffix:
Gender:F
Credentials:MA PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994
Mailing Address - Country:US
Mailing Address - Phone:772-220-3255
Mailing Address - Fax:
Practice Address - Street 1:101 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:772-220-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMHC0002621101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health