Provider Demographics
NPI:1659830834
Name:BONEM, MARILYN (PHD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BONEM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 HEAVEN DR
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48855-9409
Mailing Address - Country:US
Mailing Address - Phone:734-417-2531
Mailing Address - Fax:
Practice Address - Street 1:6 PARKLANE BLVD STE 695
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2776
Practice Address - Country:US
Practice Address - Phone:313-271-8170
Practice Address - Fax:313-271-8353
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007264103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service