Provider Demographics
NPI:1245676162
Name:BONNER, ERNEST JR (MA, CASAC, ICADC)
Entity type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:
Last Name:BONNER
Suffix:JR
Gender:M
Credentials:MA, CASAC, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1788 AMSTERDAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-3514
Mailing Address - Country:US
Mailing Address - Phone:646-529-0738
Mailing Address - Fax:
Practice Address - Street 1:1808 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6103
Practice Address - Country:US
Practice Address - Phone:646-632-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-18
Last Update Date:2013-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13120101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor