Healthcare Provider Details

I. General information

NPI: 1265869580
Provider Name (Legal Business Name): PAUL BONNELL LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3912 ISLETA BLVD SW
ALBUQUERQUE NM
87105-6131
US

IV. Provider business mailing address

3912 ISLETA BLVD SW
ALBUQUERQUE NM
87105-6131
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-1279
  • Fax: 505-848-9468
Mailing address:
  • Phone: 505-877-1279
  • Fax: 505-848-9468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-08395
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: