Provider Demographics
NPI:1265514939
Name:BONACCI, MARYELLEN MARLENE (LMSW)
Entity type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:MARLENE
Last Name:BONACCI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 RAYMO RD SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOARDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49680-9438
Mailing Address - Country:US
Mailing Address - Phone:231-258-5565
Mailing Address - Fax:
Practice Address - Street 1:438 COUNTY ROAD 612 NE
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-8577
Practice Address - Country:US
Practice Address - Phone:231-258-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010876941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical