Basic Information
| Provider Information | |||||||||
| NPI: | 1851884167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONNELL | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1995 ASH ST SW | ||||||||
| Address2: | |||||||||
| City: | DEMING | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880300793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302055675 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 BROADWAY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053458471 | ||||||||
| FaxNumber: | 5053425414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2018 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CCMH0218971 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | E.1700338 | OH | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.