Healthcare Provider Details

I. General information

NPI: 1366954968
Provider Name (Legal Business Name): BON CREATIVE CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2017
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BARBARA LOOP SE STE H
RIO RANCHO NM
87124-1088
US

IV. Provider business mailing address

11024 MONTGOMERY BLVD NE # 359
ALBUQUERQUE NM
87111-3962
US

V. Phone/Fax

Practice location:
  • Phone: 505-620-9785
  • Fax:
Mailing address:
  • Phone: 505-620-9785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberO124121
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0124121
License Number StateNM

VIII. Authorized Official

Name: BONNIE J BOUCHER
Title or Position: OWNER/DIRECTOR
Credential: LPCC
Phone: 505-620-9785