Provider Demographics
NPI:1548613425
Name:BONELLE, RAPHAEL
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:BONELLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5924 SW 12TH ST
Mailing Address - Street 2:APT 5304
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73128-5900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12000 N VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7581
Practice Address - Country:US
Practice Address - Phone:405-835-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK308629103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst