Provider Demographics
NPI:1114530102
Name:BONILLA, MAIRA ALEXANDRA
Entity Type:Individual
Prefix:
First Name:MAIRA
Middle Name:ALEXANDRA
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 1:6120 STATE HIGHWAY 359
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78332-9132
Mailing Address - Country:US
Mailing Address - Phone:361-219-0920
Mailing Address - Fax:
Practice Address - Street 1:2230 SARATOGA BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78417-3400
Practice Address - Country:US
Practice Address - Phone:361-881-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician