Healthcare Provider Details

I. General information

NPI: 1245773563
Provider Name (Legal Business Name): BONNIE GOOSIC LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BONNIE COX

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 W OLIVE AVE #140 & #200
GLENDALE AZ
85302-3843
US

IV. Provider business mailing address

3003 N CENTRAL AVE SUITE 200
PHOENIX AZ
85012-2902
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-6000
  • Fax: 602-930-0358
Mailing address:
  • Phone: 602-685-6132
  • Fax: 602-302-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-16251
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: