Provider Demographics
NPI:1790286128
Name:BONNEMA, ELLERY
Entity Type:Individual
Prefix:MISS
First Name:ELLERY
Middle Name:
Last Name:BONNEMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 BELLEGLADE CT SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8011
Mailing Address - Country:US
Mailing Address - Phone:616-745-7872
Mailing Address - Fax:
Practice Address - Street 1:3361 36TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-2809
Practice Address - Country:US
Practice Address - Phone:616-942-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician