Provider Demographics
NPI:1902462963
Name:BOMIS, DELANEY
Entity Type:Individual
Prefix:
First Name:DELANEY
Middle Name:
Last Name:BOMIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4365 LAKE FOREST DR E
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9682
Mailing Address - Country:US
Mailing Address - Phone:734-330-8957
Mailing Address - Fax:
Practice Address - Street 1:9001 MILLER RD STE 5
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-1115
Practice Address - Country:US
Practice Address - Phone:810-937-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
2348OtherAUTISM SYSTEMS