Provider Demographics
NPI:1922584176
Name:BONIFAS, BRIDGETTE LEE
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:LEE
Last Name:BONIFAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIDGETTE
Other - Middle Name:L
Other - Last Name:BONIFAS-SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 933421
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-4000
Mailing Address - Fax:937-641-4500
Practice Address - Street 1:1016 RAINBOW CT
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6365
Practice Address - Country:US
Practice Address - Phone:937-641-3401
Practice Address - Fax:937-641-3046
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2023-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2303747101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional