Provider Demographics
NPI:1114480449
Name:YARDLEY, BONNIE BLEU (LAC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:BLEU
Last Name:YARDLEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 N WINDSOR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-6811
Mailing Address - Country:US
Mailing Address - Phone:928-965-9889
Mailing Address - Fax:
Practice Address - Street 1:1234 S POWER RD STE 250
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3742
Practice Address - Country:US
Practice Address - Phone:602-633-5032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16459101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional