Provider Demographics
NPI:1447902309
Name:DURBIN, BONNIE
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:DURBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 EDISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2561 DELMAR AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3429
Practice Address - Country:US
Practice Address - Phone:618-999-1668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251E1200X, 242T00000X, 246QB0000X, 246QC2700X, 246Y00000X, 246Z00000X, 251K00000X, 101YP2500X
IL261QR1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
No246QB0000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyBlood BankingGroup - Single Specialty
No246QC2700XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyCytotechnology
No246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No251K00000XAgenciesPublic Health or Welfare
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch