Provider Demographics
NPI:1588483762
Name:ROE, BONNIE (LPT)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:ROE
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7620 CASTANO AVE
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-5233
Mailing Address - Country:US
Mailing Address - Phone:805-459-2826
Mailing Address - Fax:
Practice Address - Street 1:6500 MORRO RD STE D
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4142
Practice Address - Country:US
Practice Address - Phone:805-459-2826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41652167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician