Organization
BONITA WICKSTROM INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BONITA WICKSTROM LISW (PRESIDENT)
(505) 275-7795
Entity
Organization
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
1041C0700X
Clinical Social Worker
Primary
I4390
NM
Other
Enumeration date
06/17/2006
Last updated
01/29/2008
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