Provider Demographics
NPI:1083318091
Name:BONILLA, JANEEN
Entity Type:Individual
Prefix:
First Name:JANEEN
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:PO BOX 9925
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92552-1925
Mailing Address - Country:US
Mailing Address - Phone:951-965-6063
Mailing Address - Fax:
Practice Address - Street 1:16335 AVENIDA DE LORING
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-2076
Practice Address - Country:US
Practice Address - Phone:951-965-6063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT126765106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist