Provider Demographics
NPI:1841523586
Name:CRUSALIS, BONNIE (LMHC)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:
Last Name:CRUSALIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 LOS ALAMOS AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1120
Mailing Address - Country:US
Mailing Address - Phone:505-243-3353
Mailing Address - Fax:505-247-1020
Practice Address - Street 1:4308 CARLISLE BLVD NE
Practice Address - Street 2:#210
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4856
Practice Address - Country:US
Practice Address - Phone:505-247-1921
Practice Address - Fax:505-247-1020
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0116661101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor