Healthcare Provider Details

I. General information

NPI: 1457422776
Provider Name (Legal Business Name): BONNIE GILL M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

624 E MESA DR
HOBBS NM
88240-4024
US

IV. Provider business mailing address

624 E MESA DR
HOBBS NM
88240-4024
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-4415
  • Fax:
Mailing address:
  • Phone: 505-397-4415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI04896
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number38850
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: