Provider Demographics
NPI:1972673036
Name:BRONSON, BONNY GALE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNY
Middle Name:GALE
Last Name:BRONSON
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 1:920 9 1 2 ST NE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5311
Mailing Address - Country:US
Mailing Address - Phone:434-984-1311
Mailing Address - Fax:434-971-7740
Practice Address - Street 1:920 9 1 2 ST NE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5311
Practice Address - Country:US
Practice Address - Phone:434-984-1311
Practice Address - Fax:434-971-7740
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001884103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7707983Medicaid
071737OtherANTHEM
11510778OtherCAQH
VA7707983Medicaid