Provider Demographics
NPI:1144274689
Name:DEBBAN, BONITA JEAN (PHD)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:JEAN
Last Name:DEBBAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 S SILVER LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3802
Mailing Address - Country:US
Mailing Address - Phone:262-567-7900
Mailing Address - Fax:262-567-7908
Practice Address - Street 1:970 S SILVER LAKE ST
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3802
Practice Address - Country:US
Practice Address - Phone:262-567-7900
Practice Address - Fax:262-567-7908
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2324-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43550000Medicaid
WI412024650011OtherBLUE CROSS BLUE SHIELD