Basic Information
| Provider Information | |||||||||
| NPI: | 1083741334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATLOCK | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | ESTHER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.C., L.M.F.T. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 247 CHATEAU DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358016401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039659545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 247 CHATEAU DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358016401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565339393 | ||||||||
| FaxNumber: | 2565339690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 05/04/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2773 | AL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 224420000 | 01 | VA | MAGELLAN INFORMATION SYST | OTHER |