Provider Demographics
NPI:1477011872
Name:BONILLA, COURTNEY DYAN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:DYAN
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:COURTNEY
Other - Middle Name:DYAN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:633 BERKMAR CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901
Mailing Address - Country:US
Mailing Address - Phone:434-305-6731
Mailing Address - Fax:
Practice Address - Street 1:633 BERKMAR CIRCLE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901
Practice Address - Country:US
Practice Address - Phone:434-305-6731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008115101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional