Provider Demographics
NPI:1558881227
Name:BONILLA, ANTHONY JR
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:BONILLA
Suffix:JR
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 1:1022 PROSPECT ST APT 902
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-3470
Mailing Address - Country:US
Mailing Address - Phone:808-783-6284
Mailing Address - Fax:
Practice Address - Street 1:2 AARONA PL STE 208
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2546
Practice Address - Country:US
Practice Address - Phone:808-263-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician