Provider Demographics
NPI:1053896506
Name:MULLETT, BONNIE
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:MULLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:MANNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2697
Mailing Address - Country:US
Mailing Address - Phone:833-510-4357
Mailing Address - Fax:664-602-9978
Practice Address - Street 1:3911 N MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3202
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:866-460-2997
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
KY251828101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker