Provider Demographics
NPI:1376033837
Name:BONNER, CHARLENE MARIE (PSYD)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:MARIE
Last Name:BONNER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 COUNTRY CLUB WAY
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364-4121
Mailing Address - Country:US
Mailing Address - Phone:617-838-3991
Mailing Address - Fax:
Practice Address - Street 1:276 COUNTRY CLUB WAY
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02364-4121
Practice Address - Country:US
Practice Address - Phone:617-838-3991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
8742103TA0400X
MA8742103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)