Provider Demographics
NPI:1659488583
Name:BONACCI, CARL ALBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ALBERT
Last Name:BONACCI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 E COLTER ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3048
Mailing Address - Country:US
Mailing Address - Phone:928-257-4897
Mailing Address - Fax:866-534-1701
Practice Address - Street 1:1349 E COLTER ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-3048
Practice Address - Country:US
Practice Address - Phone:928-257-4897
Practice Address - Fax:866-534-1701
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3376103G00000X, 103T00000X, 103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ564527Medicaid
AZ564527Medicaid
AZ79289Medicare ID - Type UnspecifiedPERSONAL MENTUS
AZP26625Medicare UPIN