Provider Demographics
NPI:1982170262
Name:VAN BONN, MARY MILDRED (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MILDRED
Last Name:VAN BONN
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1828
Mailing Address - Country:US
Mailing Address - Phone:616-209-9577
Mailing Address - Fax:
Practice Address - Street 1:512 WASHINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1455
Practice Address - Country:US
Practice Address - Phone:616-209-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016842101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional