Provider Demographics
NPI:1558926766
Name:BONILLA, KRISTIN M (LADC AADC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LADC AADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 COSTANZO CT
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-2464
Mailing Address - Country:US
Mailing Address - Phone:203-556-4969
Mailing Address - Fax:
Practice Address - Street 1:6 COSTANZO CT
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-2464
Practice Address - Country:US
Practice Address - Phone:203-556-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000035101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000035OtherCT DPH