Basic Information
| Provider Information | |||||||||
| NPI: | 1275704777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOMMARITO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | DANTE | ||||||||
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| Credential: | PROFESSIONAL COUNSEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13001 23 MILE RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483152767 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13001 23 MILE RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483152767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2008 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401010326 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | 6401010326 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.