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General NPI Number Information
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NPI Number | 1548205289
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Entity Type | Organization
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Legal Business Name | BONITA WICKSTROM INC
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Dates
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Enumeration Date | 06/17/2006
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Last Update Date | 01/29/2008
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Provider Practice Location Address
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Address Line | 12836 LOMAS BLVD NE SUITE B
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City | ALBUQUERQUE
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State | NM
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Zip | 87112-6210
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Country | US
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Telephone | 505-453-7862
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Fax |
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Provider Business Mailing Address
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Address Line | 14507 ENCANTADO RD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87123-2249
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Country | US
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Telephone | 505-275-7795
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BONITA WICKSTROM
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Credential | LISW
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Telephone | 505-275-7795
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I4390
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License Number State | NM
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