Basic Information
| Provider Information | |||||||||
| NPI: | 1154762839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONOW | ||||||||
| FirstName: | MARY CLARE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N BRAND BLVD | ||||||||
| Address2: | #1000 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912031906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182416780 | ||||||||
| FaxNumber: | 8182416853 | ||||||||
| Practice Location | |||||||||
| Address1: | 2822 E ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955014332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888050759 | ||||||||
| FaxNumber: | 8182416853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2013 | ||||||||
| LastUpdateDate: | 07/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-13-13690 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-13-13690 | 01 | CA | BCBA | OTHER |