Provider Demographics
NPI:1891801619
Name:BONNER, MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BONNER
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 1:106 MILFORD ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-6953
Mailing Address - Country:US
Mailing Address - Phone:410-543-8291
Mailing Address - Fax:410-341-6275
Practice Address - Street 1:106 MILFORD ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6953
Practice Address - Country:US
Practice Address - Phone:410-543-8291
Practice Address - Fax:410-341-6275
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3523103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD821701700Medicaid
MDR55460Medicare UPIN
MD821701700Medicaid