Provider Demographics
NPI:1760637342
Name:SAXON, BONNY LEE (BA, LMT)
Entity type:Individual
Prefix:MS
First Name:BONNY
Middle Name:LEE
Last Name:SAXON
Suffix:
Gender:F
Credentials:BA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WATER ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:ME
Mailing Address - Zip Code:04346-5101
Mailing Address - Country:US
Mailing Address - Phone:207-582-8158
Mailing Address - Fax:
Practice Address - Street 1:129 WATER ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:ME
Practice Address - Zip Code:04346-5101
Practice Address - Country:US
Practice Address - Phone:207-582-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME417174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEVC0000105553Medicaid