Provider Demographics
NPI:1902825466
Name:BLUE, BONNIE BEAU (MFT)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:BEAU
Last Name:BLUE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 LEAD HILL BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2941
Mailing Address - Country:US
Mailing Address - Phone:916-481-8171
Mailing Address - Fax:916-786-3080
Practice Address - Street 1:1380 LEAD HILL BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2941
Practice Address - Country:US
Practice Address - Phone:916-481-8171
Practice Address - Fax:916-786-3080
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT41114106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist