Provider Demographics
NPI:1407210784
Name:BONILLA BERMUDEZ, DANIELA ALEJANDRA (LADC)
Entity Type:Individual
Prefix:
First Name:DANIELA
Middle Name:ALEJANDRA
Last Name:BONILLA BERMUDEZ
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 EXCELSIOR BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2734
Mailing Address - Country:US
Mailing Address - Phone:952-548-9354
Mailing Address - Fax:952-925-3264
Practice Address - Street 1:6200 EXCELSIOR BLVD STE 203
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2734
Practice Address - Country:US
Practice Address - Phone:952-548-9354
Practice Address - Fax:952-925-3264
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)