Provider Demographics
NPI:1669937041
Name:BURY-BLATTMAN, BONNIE ROSE (LPC)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:ROSE
Last Name:BURY-BLATTMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10116 SPARKS DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-3935
Mailing Address - Country:US
Mailing Address - Phone:903-565-9022
Mailing Address - Fax:833-953-1521
Practice Address - Street 1:100 INDEPENDENCE PL STE 201
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1327
Practice Address - Country:US
Practice Address - Phone:903-565-9022
Practice Address - Fax:833-953-1521
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-09
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11745101YA0400X
TX80342101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX396545103Medicaid