Basic Information
| Provider Information | |||||||||
| NPI: | 1629377312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONSU | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144567000 | ||||||||
| FaxNumber: | 2144566133 | ||||||||
| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753907208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144562382 | ||||||||
| FaxNumber: | 2144566133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 10/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 34498 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | 2080P0207X | 34498 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
No ID Information.