Provider Demographics
NPI:1598399099
Name:BONILLA, EMMA REAL (LCPC)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:REAL
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5117B MAIN ST STE 12
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-4602
Mailing Address - Country:US
Mailing Address - Phone:312-620-0546
Mailing Address - Fax:
Practice Address - Street 1:5117B MAIN ST STE 12
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4602
Practice Address - Country:US
Practice Address - Phone:312-620-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015519101YP2500X
IL180.014199101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional