Provider Demographics
NPI:1437727245
Name:BONILLA DIAZ, RICHAR LAZARO (BS/TCM)
Entity Type:Individual
Prefix:
First Name:RICHAR
Middle Name:LAZARO
Last Name:BONILLA DIAZ
Suffix:
Gender:M
Credentials:BS/TCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 NW 75TH ST
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33166-2549
Mailing Address - Country:US
Mailing Address - Phone:786-593-2713
Mailing Address - Fax:
Practice Address - Street 1:15924 SW 92ND AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1842
Practice Address - Country:US
Practice Address - Phone:305-964-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker