Provider Demographics
NPI:1063022457
Name:MCCALLISTER-VON BONIN, PENNY S (LPCC)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:S
Last Name:MCCALLISTER-VON BONIN
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 1:624 SOLAR RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5744
Mailing Address - Country:US
Mailing Address - Phone:505-321-3362
Mailing Address - Fax:
Practice Address - Street 1:2440 LOUISIANA BLVD NE STE 300
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4394
Practice Address - Country:US
Practice Address - Phone:505-302-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0212541101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional