Healthcare Provider Details

I. General information

NPI: 1841296621
Provider Name (Legal Business Name): BONNIE L. SHETLER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 REMINGTON ST
FORT COLLINS CO
80524-3024
US

IV. Provider business mailing address

649 REMINGTON ST
FORT COLLINS CO
80524-3024
US

V. Phone/Fax

Practice location:
  • Phone: 970-224-5467
  • Fax: 970-224-4760
Mailing address:
  • Phone: 970-224-5467
  • Fax: 970-224-4760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1128
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: