Provider Demographics
NPI:1245651389
Name:BONAHOOM, ALICIA (MA, LLP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BONAHOOM
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N OLD WOODWARD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-3855
Mailing Address - Country:US
Mailing Address - Phone:313-909-2363
Mailing Address - Fax:
Practice Address - Street 1:202 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-2907
Practice Address - Country:US
Practice Address - Phone:313-909-2363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011059106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist