Provider Demographics
NPI:1326772690
Name:BONILLA, MARIA DE LA LUZ (LMT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:DE LA LUZ
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E HOMER DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-3053
Mailing Address - Country:US
Mailing Address - Phone:719-419-0890
Mailing Address - Fax:
Practice Address - Street 1:1825 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-1100
Practice Address - Country:US
Practice Address - Phone:719-390-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0021665225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist