Provider Demographics
NPI:1932582608
Name:BONITA, ANTHONY G (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:G
Last Name:BONITA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8000
Mailing Address - Fax:
Practice Address - Street 1:5191 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-9137
Practice Address - Country:US
Practice Address - Phone:231-946-1979
Practice Address - Fax:231-946-1984
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015747103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical