Provider Demographics
NPI:1073758918
Name:BONILLA, JOSE RICHARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:RICHARD
Last Name:BONILLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 CYPRESS LN E
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5709
Mailing Address - Country:US
Mailing Address - Phone:516-305-9366
Mailing Address - Fax:
Practice Address - Street 1:120 BETHPAGE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-1515
Practice Address - Country:US
Practice Address - Phone:516-305-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-06
Last Update Date:2008-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069580-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical