Provider Demographics
NPI:1376265264
Name:BONILLA, MERLYN (LMT)
Entity Type:Individual
Prefix:
First Name:MERLYN
Middle Name:
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 1:730 HEBRON AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5016
Mailing Address - Country:US
Mailing Address - Phone:860-410-4490
Mailing Address - Fax:860-410-4492
Practice Address - Street 1:730 HEBRON AVE STE 3
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5016
Practice Address - Country:US
Practice Address - Phone:860-410-4490
Practice Address - Fax:860-410-4492
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11012225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist