Provider Demographics
NPI:1881603033
Name:KISER, BONNIE BEA
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:BEA
Last Name:KISER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3948 NEW VISION DR STE D
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1721
Mailing Address - Country:US
Mailing Address - Phone:260-407-7285
Mailing Address - Fax:260-407-0094
Practice Address - Street 1:3948 NEW VISION DR STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1721
Practice Address - Country:US
Practice Address - Phone:260-407-7285
Practice Address - Fax:260-407-0094
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INLMFT 35001593A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200530260AMedicaid