Provider Demographics
NPI:1396208849
Name:BONILLA, LESLIE E
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:E
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 1:3 S 34TH ST
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-3618
Mailing Address - Country:US
Mailing Address - Phone:631-220-0541
Mailing Address - Fax:
Practice Address - Street 1:225 BROADHOLLOW RD STE 402
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4899
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician