Basic Information
| Provider Information | |||||||||
| NPI: | 1801923339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WINKLEMAN | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2780 S JONES BLVD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891465628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883202271 | ||||||||
| FaxNumber: | 8887655221 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 E MT GARFIELD RD STE 135 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494447732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317998880 | ||||||||
| FaxNumber: | 2317998803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY0405 | NV | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | PY0405 | NV | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC1900X | 6301017020 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC0700X | 6301017020 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1801923339 | 05 | NV | MEDICAID | 002602083 | 05 | NV | MEDICAID |