Provider Demographics
NPI:1033841655
Name:BONILLA, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 VENTURA BLVD STE 414
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-5050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5901 GREEN VALLEY CIR STE 466
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6970
Practice Address - Country:US
Practice Address - Phone:951-455-2447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician