Provider Demographics
NPI:1073779914
Name:BONILLA, MARIA MAGDALENA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:MAGDALENA
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 1:562 NW LA BREA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8703
Mailing Address - Country:US
Mailing Address - Phone:772-344-9554
Mailing Address - Fax:
Practice Address - Street 1:15818 SW WARFIELD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANTOWN
Practice Address - State:FL
Practice Address - Zip Code:34956-3513
Practice Address - Country:US
Practice Address - Phone:772-597-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health