Provider Demographics
NPI:1518024686
Name:WHITE, BONNY J (MFT)
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:J
Last Name:WHITE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11024 BALBOA BLVD
Mailing Address - Street 2:#615
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-5007
Mailing Address - Country:US
Mailing Address - Phone:818-268-9273
Mailing Address - Fax:
Practice Address - Street 1:11260 WILBUR AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-2450
Practice Address - Country:US
Practice Address - Phone:818-268-9273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39598101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health