Healthcare Provider Details

I. General information

NPI: 1366863706
Provider Name (Legal Business Name): BONNIE JEAN EVANS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BIG SKY AVE SW
LOS LUNAS NM
87031-6155
US

IV. Provider business mailing address

01 SAGEBRUSH ST
ISLETA NM
87022-0000
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-9026
  • Fax:
Mailing address:
  • Phone: 505-869-5479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0097631
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0104231
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: