Provider Demographics
NPI:1831199678
Name:BONN, GARY (MSW)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BONN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 NORA ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49548-5949
Mailing Address - Country:US
Mailing Address - Phone:616-532-0145
Mailing Address - Fax:
Practice Address - Street 1:1142 44TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7557
Practice Address - Country:US
Practice Address - Phone:616-534-8323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020778231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical