Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) |
NPI | 1316477250 |
---|---|
Provider Name | Stephanie Bonilla |
First Address | Wilmington, CA 90744-2639 |
Second Address | Wilmington, CA 90744-2639 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2017 |
Last Update Date | 13/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6197-R | (05) | CA |