Individual
MS. BONITA RAE WICKSTROM
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
LISW
Contact information
Practice address
12836 LOMAS BLVD NE, SUITE B, ALBUQUERQUE, NM 87112-6210
(505) 453-7862
Mailing address
14507 ENCANTADO RD NE, ALBUQUERQUE, NM 87123-2249
(505) 275-7795
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
I-4390
NM
Other
Enumeration date
05/31/2006
Last updated
07/08/2007
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