Basic Information
| Provider Information | |||||||||
| NPI: | 1275558264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREIDENBACH | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | AYER | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 WOODBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | ST CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867793862 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24715 LITTLE MACK AVE | ||||||||
| Address2: | |||||||||
| City: | ST CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480803207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867779000 | ||||||||
| FaxNumber: | 5867770823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YM0800X | CNS 6401005658 | MI | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TB0200X | LLP6301009372 | MI | X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
No ID Information.