Provider Demographics
NPI:1548358583
Name:BOUCHER, BONNIE
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:DIETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 11068
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87192-0068
Mailing Address - Country:US
Mailing Address - Phone:505-620-9785
Mailing Address - Fax:
Practice Address - Street 1:10801 LOMAS BLVD NE STE 105
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5474
Practice Address - Country:US
Practice Address - Phone:505-620-9785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0065142101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12349OtherLOVELACE HEALTH PLAN