Provider Demographics
NPI:1467823989
Name:CARLSON, BONNIE LEE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:LEE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:LEE
Other - Last Name:WHYNAUCHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1514
Mailing Address - Country:US
Mailing Address - Phone:510-574-2205
Mailing Address - Fax:
Practice Address - Street 1:3300 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1514
Practice Address - Country:US
Practice Address - Phone:510-574-2205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health