=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245865468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONNIE MARIE CATANACH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2020
-----------------------------------------------------
Last Update Date | 03/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3136 JEMEZ RD
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-8004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-603-1353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3136 JEMEZ RD
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-8004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-603-1353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CSA0210251
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------