Provider Demographics
NPI:1770674038
Name:NEELY, BONNIE MARIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:MARIE
Last Name:NEELY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CATHDRAL LANE
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554
Mailing Address - Country:US
Mailing Address - Phone:540-720-1191
Mailing Address - Fax:
Practice Address - Street 1:305 HANSON AVE
Practice Address - Street 2:STE 170
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-361-4330
Practice Address - Fax:540-361-4331
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002528101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
217867OtherBCBS
324122OtherMHN