Provider Demographics
NPI:1841398567
Name:ISACKE, BONNIE WAGONER (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:WAGONER
Last Name:ISACKE
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 1:201 PENN CENTER BLVD
Mailing Address - Street 2:SUITE 555
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15235-5442
Mailing Address - Country:US
Mailing Address - Phone:412-421-0184
Mailing Address - Fax:412-261-4276
Practice Address - Street 1:201 PENN CENTER BLVD
Practice Address - Street 2:SUITE 555
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15235-5442
Practice Address - Country:US
Practice Address - Phone:412-421-0184
Practice Address - Fax:412-261-4276
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006785L103T00000X
PASL000239L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA743751OtherHIGHMARK BCBS PSYCHOLOGY