Provider Demographics
NPI:1801171376
Name:STANLEY, BONNIE GRACE (MED,EDS)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:GRACE
Last Name:STANLEY
Suffix:
Gender:F
Credentials:MED,EDS
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:GRACE
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1134 W WINGED FOOT CIR
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-4203
Mailing Address - Country:US
Mailing Address - Phone:407-365-8994
Mailing Address - Fax:
Practice Address - Street 1:1350 N ORANGE AVE
Practice Address - Street 2:SUITE200
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4945
Practice Address - Country:US
Practice Address - Phone:407-644-4367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS996103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSS996OtherLICENSED SCHOOL PSYCHOLOGIST