Provider Demographics
NPI:1255695110
Name:BONILLA, BERONICA (LCSW-C)
Entity Type:Individual
Prefix:
First Name:BERONICA
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 NORTH CHARLES ST.
Mailing Address - Street 2:CREDENTIALING-CARLA CASH
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6819
Mailing Address - Country:US
Mailing Address - Phone:443-761-5294
Mailing Address - Fax:434-420-9454
Practice Address - Street 1:604 SOLAREX CT UNIT 201
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8655
Practice Address - Country:US
Practice Address - Phone:301-663-8263
Practice Address - Fax:301-682-5326
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD180921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD816700100Medicaid