Provider Demographics
NPI:1881149433
Name:BONANDER, CLARENCE LEONARD JR
Entity type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:LEONARD
Last Name:BONANDER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-379-1704
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:817 MAIN ST N
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1275
Practice Address - Country:US
Practice Address - Phone:763-325-0300
Practice Address - Fax:763-325-0301
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MNGL0087103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health