Provider Demographics
NPI:1972573970
Name:MICHALIK-BONNER, DIANE ROSE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ROSE
Last Name:MICHALIK-BONNER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-1801
Mailing Address - Country:US
Mailing Address - Phone:570-374-4305
Mailing Address - Fax:570-374-4305
Practice Address - Street 1:3 S MARKET ST
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-1801
Practice Address - Country:US
Practice Address - Phone:570-374-4305
Practice Address - Fax:570-374-4305
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006150-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA700639Medicare UPIN