Provider Demographics
NPI:1356997324
Name:BONNER, MICHAEL (LPC-S)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BONNER
Suffix:
Gender:M
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 CHISHOLM TRL STE 506
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-2970
Mailing Address - Country:US
Mailing Address - Phone:512-501-5449
Mailing Address - Fax:
Practice Address - Street 1:1311 CHISHOLM TRL STE 506
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-2970
Practice Address - Country:US
Practice Address - Phone:512-501-5449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68551101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional