Healthcare Provider Details

I. General information

NPI: 1851884167
Provider Name (Legal Business Name): BEVERLY JEAN BONNELL LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2360
US

IV. Provider business mailing address

1995 ASH ST SW
DEMING NM
88030-0793
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-8471
  • Fax: 505-342-5414
Mailing address:
  • Phone: 330-205-5675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0218971
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1700338
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: