Provider Demographics
NPI:1366863706
Name:EVANS, BONNIE JEAN (LPCC)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:01 SAGEBRUSH ST
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0000
Mailing Address - Country:US
Mailing Address - Phone:505-869-5479
Mailing Address - Fax:
Practice Address - Street 1:111 BIG SKY AVE SW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6155
Practice Address - Country:US
Practice Address - Phone:505-865-9026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0097631101YA0400X
NMCCMH0104231101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0097631OtherLICENSE