Provider Demographics
NPI:1679800254
Name:MCCLINTOCK, BONNIE COLLEEN (BS, OT)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:COLLEEN
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:BS, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 RINCON CT
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5271
Mailing Address - Country:US
Mailing Address - Phone:505-603-8224
Mailing Address - Fax:
Practice Address - Street 1:2701 RINCON CT
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5271
Practice Address - Country:US
Practice Address - Phone:505-603-8224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2693225X00000X
CAOT427225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist