Provider Demographics
NPI:1083741334
Name:MATLOCK, BONNIE ESTHER (LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ESTHER
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 CHATEAU DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6401
Mailing Address - Country:US
Mailing Address - Phone:703-965-9545
Mailing Address - Fax:
Practice Address - Street 1:247 CHATEAU DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6401
Practice Address - Country:US
Practice Address - Phone:256-533-9393
Practice Address - Fax:256-533-9690
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2773101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA224420000OtherMAGELLAN INFORMATION SYST
VA900108903OtherEIN NUMBER
VA100952Medicare UPIN