Provider Demographics
NPI:1548643414
Name:HAVOC, BONNY JO
Entity type:Individual
Prefix:
First Name:BONNY JO
Middle Name:
Last Name:HAVOC
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 1:10900 RESEARCH BLVD
Mailing Address - Street 2:SUITE 100-C
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5722
Mailing Address - Country:US
Mailing Address - Phone:512-487-5665
Mailing Address - Fax:
Practice Address - Street 1:10900 RESEARCH BLVD
Practice Address - Street 2:SUITE 100-C
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5722
Practice Address - Country:US
Practice Address - Phone:512-487-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80671237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist