Provider Demographics
NPI:1801222005
Name:BONNER, ANTHONY (BS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BONNER
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17535 MANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-4056
Mailing Address - Country:US
Mailing Address - Phone:313-495-4012
Mailing Address - Fax:
Practice Address - Street 1:4251 E. MCNICHOLS
Practice Address - Street 2:
Practice Address - City:HAMTRACK
Practice Address - State:MI
Practice Address - Zip Code:48205
Practice Address - Country:US
Practice Address - Phone:313-368-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)