Healthcare Provider Details

I. General information

NPI: 1548205289
Provider Name (Legal Business Name): BONITA WICKSTROM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12836 LOMAS BLVD NE SUITE B
ALBUQUERQUE NM
87112-6210
US

IV. Provider business mailing address

14507 ENCANTADO RD NE
ALBUQUERQUE NM
87123-2249
US

V. Phone/Fax

Practice location:
  • Phone: 505-453-7862
  • Fax:
Mailing address:
  • Phone: 505-275-7795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI4390
License Number StateNM

VIII. Authorized Official

Name: BONITA WICKSTROM
Title or Position: PRESIDENT
Credential: LISW
Phone: 505-275-7795