Provider Demographics
NPI:1144418971
Name:BONILLA, SARAH ELLEN
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ELLEN
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 1:516 W CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6748
Mailing Address - Country:US
Mailing Address - Phone:909-528-4403
Mailing Address - Fax:
Practice Address - Street 1:1255 W COLTON AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2861
Practice Address - Country:US
Practice Address - Phone:909-528-4403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49788106H00000X
CAIMF 54403106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist