Healthcare Provider Details

I. General information

NPI: 1841523586
Provider Name (Legal Business Name): BONNIE CRUSALIS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 CARLISLE BLVD NE #210
ALBUQUERQUE NM
87107-4856
US

IV. Provider business mailing address

1520 LOS ALAMOS AVE SW
ALBUQUERQUE NM
87104-1120
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-1921
  • Fax: 505-247-1020
Mailing address:
  • Phone: 505-243-3353
  • Fax: 505-247-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0116661
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: