Provider Demographics
NPI:1871628776
Name:FICK, BONNIE LOU I (LICSW)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:LOU
Last Name:FICK
Suffix:I
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 TRACY PLACE
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5270
Mailing Address - Country:US
Mailing Address - Phone:505-234-3318
Mailing Address - Fax:505-234-3452
Practice Address - Street 1:1131 TRACY PLACE
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220
Practice Address - Country:US
Practice Address - Phone:505-234-3318
Practice Address - Fax:505-234-3452
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI055451041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS0147Medicaid