Provider Demographics
NPI:1831169408
Name:WALDNER, BONITA (MSW)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:WALDNER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:BONITA
Other - Middle Name:
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:404 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-1924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1019 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-1025
Practice Address - Country:US
Practice Address - Phone:573-885-1607
Practice Address - Fax:573-885-0428
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999140933104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494838311Medicaid
MO000080817Medicare ID - Type Unspecified