Provider Demographics
NPI:1184783698
Name:BONIE, KATHLEEN A (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:BONIE
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 1:1136 WILMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420
Mailing Address - Country:US
Mailing Address - Phone:937-254-6700
Mailing Address - Fax:937-254-6776
Practice Address - Street 1:1136 WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420
Practice Address - Country:US
Practice Address - Phone:937-254-6700
Practice Address - Fax:937-254-6776
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3782103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBOCPO7252Medicare ID - Type Unspecified