MEDICARE: DR. BONNIE STETSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	264138	NM

General Provider Information

NPI Number	:	1053507608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONNIE STETSON PH.D.

Provider Business Mailing Address
First Line	:	9434 RIO GRANDE BLVD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-1813
Country	:	US
Telephone Number	:	505-899-9088
Fax Number	:	505-898-0250

Provider Business Practice Location Address
First Line	:	9434 RIO GRANDE BLVD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-1813
Country	:	US
Telephone Number	:	505-899-9088
Fax Number	:	505-898-0250

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	09/18/2007

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