Provider Demographics
NPI:1326536822
Name:BONILLA, DAISY
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:
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 1:118 N 2ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2894
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:636-946-0991
Practice Address - Street 1:1200 W WALNUT ST STE 3100
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3524
Practice Address - Country:US
Practice Address - Phone:479-631-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8569-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker