Provider Demographics
NPI:1790173144
Name:POWERS, BONITA LYN I
Entity Type:Individual
Prefix:MS
First Name:BONITA
Middle Name:LYN
Last Name:POWERS
Suffix:I
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BONITA
Other - Middle Name:L
Other - Last Name:POWERS
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1206 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2811
Mailing Address - Country:US
Mailing Address - Phone:505-747-7400
Mailing Address - Fax:505-747-7403
Practice Address - Street 1:1206 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2811
Practice Address - Country:US
Practice Address - Phone:505-747-7400
Practice Address - Fax:505-747-7403
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical