Healthcare Provider Details

I. General information

NPI: 1548358583
Provider Name (Legal Business Name): MRS. BONNIE BOUCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BONNIE DIETZ

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 LOMAS BLVD NE STE 105
ALBUQUERQUE NM
87112-5474
US

IV. Provider business mailing address

PO BOX 11068
ALBUQUERQUE NM
87192-0068
US

V. Phone/Fax

Practice location:
  • Phone: 505-620-9785
  • Fax:
Mailing address:
  • Phone: 505-620-9785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0065142
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: