Provider Demographics
NPI:1083822084
Name:SMITH, BUNNY LEIGH (LMSW)
Entity Type:Individual
Prefix:
First Name:BUNNY
Middle Name:LEIGH
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ROAD 5256
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-9779
Mailing Address - Country:US
Mailing Address - Phone:505-632-1403
Mailing Address - Fax:
Practice Address - Street 1:520 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-5307
Practice Address - Country:US
Practice Address - Phone:505-634-3441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-40241041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool