Provider Demographics
NPI:1497338339
Name:BONILLA, MICHELLE (LMHC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 N FELTUS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-1245
Mailing Address - Country:US
Mailing Address - Phone:908-342-6255
Mailing Address - Fax:
Practice Address - Street 1:401 BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-2010
Practice Address - Country:US
Practice Address - Phone:718-300-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011255101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health