Provider Demographics
NPI:1144609686
Name:BONISTALLI, CAROLYN (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BONISTALLI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4806 FAIR ELMS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1709
Mailing Address - Country:US
Mailing Address - Phone:708-732-0654
Mailing Address - Fax:
Practice Address - Street 1:4806 FAIR ELMS AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1709
Practice Address - Country:US
Practice Address - Phone:708-732-0654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490170411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical