Provider Demographics
NPI:1932250578
Name:BONANNO, GINA MARIE (MED, CAGS, LMHC)
Entity Type:Individual
Prefix:
First Name:GINA MARIE
Middle Name:
Last Name:BONANNO
Suffix:
Gender:F
Credentials:MED, CAGS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-6415
Mailing Address - Country:US
Mailing Address - Phone:978-416-7885
Mailing Address - Fax:
Practice Address - Street 1:286 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-6415
Practice Address - Country:US
Practice Address - Phone:978-416-7885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5254101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALM1095OtherBLUE CROSS