Healthcare Provider Details

I. General information

NPI: 1063022457
Provider Name (Legal Business Name): PENNY S MCCALLISTER-VON BONIN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 LOUISIANA BLVD NE STE 300
ALBUQUERQUE NM
87110-4394
US

IV. Provider business mailing address

624 SOLAR RD NW
ALBUQUERQUE NM
87107-5744
US

V. Phone/Fax

Practice location:
  • Phone: 505-302-1660
  • Fax:
Mailing address:
  • Phone: 505-321-3362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0212541
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: