Healthcare Provider Details

I. General information

NPI: 1174571046
Provider Name (Legal Business Name): BONNIE J AUTRY-BURKE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 S 7TH ST
GRAND JUNCTION CO
81501-7731
US

IV. Provider business mailing address

PO BOX 40
GLENWOOD SPRINGS CO
81602-0040
US

V. Phone/Fax

Practice location:
  • Phone: 970-245-4213
  • Fax: 970-243-7297
Mailing address:
  • Phone: 970-945-2241
  • Fax: 970-945-5523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6283
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: