Provider Demographics
NPI:1396115218
Name:IRWIN, BONNIE W (PSYA D)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:W
Last Name:IRWIN
Suffix:
Gender:F
Credentials:PSYA D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 5
Mailing Address - Street 2:
Mailing Address - City:THETFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05074
Mailing Address - Country:US
Mailing Address - Phone:802-785-4581
Mailing Address - Fax:
Practice Address - Street 1:331 UPPER PLAIN
Practice Address - Street 2:BRADFORD MEDICAL CENTER
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033
Practice Address - Country:US
Practice Address - Phone:802-222-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT098.0133628102L00000X
103TP2701X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy