MEDICARE: BONITA FERN WICHER LCDC, ADC-III, SAP

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	8405	TX

General Provider Information

NPI Number	:	1801133517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONITA FERN WICHER LCDC, ADC-III, SAP

Provider Business Mailing Address
First Line	:	17629 EL CAMINO REAL
Second Line	:	SUITE 115
City	:	HOUSTON
State	:	TX
Zip	:	77058-2901
Country	:	US
Telephone Number	:	281-971-1969
Fax Number	:

Provider Business Practice Location Address
First Line	:	17629 EL CAMINO REAL
Second Line	:	SUITE 115
City	:	HOUSTON
State	:	TX
Zip	:	77058-2901
Country	:	US
Telephone Number	:	281-971-1969
Fax Number	:

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

Provider Enumeration Date	:	01/15/2013
Last Update Date	:	01/15/2013

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