Provider Demographics
NPI:1356830210
Name:BONILLA BONILLA, NELLY ESTHER (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:NELLY
Middle Name:ESTHER
Last Name:BONILLA BONILLA
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5123 W 98TH ST # 1070
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55437-2040
Mailing Address - Country:US
Mailing Address - Phone:612-475-0505
Mailing Address - Fax:
Practice Address - Street 1:5123 W 98TH ST # 1070
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55437-2040
Practice Address - Country:US
Practice Address - Phone:612-475-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRLP6839103T00000X
PR6719103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist