Provider Demographics
NPI:1730192121
Name:BONINA, JOHN MICHAEL (LICSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:BONINA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:BONINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:21 EDLIN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-1944
Mailing Address - Country:US
Mailing Address - Phone:508-757-9566
Mailing Address - Fax:
Practice Address - Street 1:21 EDLIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1944
Practice Address - Country:US
Practice Address - Phone:508-757-9566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10322651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP21501Medicare ID - Type UnspecifiedMEDICARE B