Provider Demographics
NPI:1174037832
Name:BONVILLIAN, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BONVILLIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11349 COPPERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-6087
Mailing Address - Country:US
Mailing Address - Phone:225-892-0103
Mailing Address - Fax:
Practice Address - Street 1:350 MAIN ST
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-3767
Practice Address - Country:US
Practice Address - Phone:225-778-6783
Practice Address - Fax:225-612-6602
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$Medicaid