Provider Demographics
NPI:1013356609
Name:WEBSTER, BONNIE D (MS)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:D
Last Name:WEBSTER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 RODEO PARK DR. W
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-986-9633
Mailing Address - Fax:505-473-3038
Practice Address - Street 1:222 W BROADWAY
Practice Address - Street 2:
Practice Address - City:MOUNTAINAIR
Practice Address - State:NM
Practice Address - Zip Code:87036
Practice Address - Country:US
Practice Address - Phone:505-847-2320
Practice Address - Fax:505-847-2995
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0212501101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM103356609Medicaid