1770674038 NPI number — MRS. BONNIE MARIE NEELY LPC

Table of content: MRS. BONNIE MARIE NEELY LPC (NPI 1770674038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770674038 NPI number — MRS. BONNIE MARIE NEELY LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEELY
Provider First Name:
BONNIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770674038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 CATHDRAL LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAFFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-720-1191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 HANSON AVE
Provider Second Line Business Practice Location Address:
STE 170
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-361-4330
Provider Business Practice Location Address Fax Number:
540-361-4331
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0701002528 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 217867 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 324122 . This is a "MHN" identifier . This identifiers is of the category "OTHER".




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