Provider Demographics
NPI:1245661511
Name:BONNER, IAN
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:BONNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 N CLARK ST # 215
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2290
Mailing Address - Country:US
Mailing Address - Phone:908-229-3578
Mailing Address - Fax:
Practice Address - Street 1:5315 N CLARK ST # 215
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2290
Practice Address - Country:US
Practice Address - Phone:908-229-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008712103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical