Provider Demographics
NPI:1578835518
Name:BECKSTROM, BONNIE JANE (PPC-1479)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:JANE
Last Name:BECKSTROM
Suffix:
Gender:F
Credentials:PPC-1479
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:WHEATLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82201-0472
Mailing Address - Country:US
Mailing Address - Phone:307-331-7869
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 472
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-0472
Practice Address - Country:US
Practice Address - Phone:307-331-7869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1479101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty