Provider Demographics
NPI:1639716137
Name:BONNER, CHANTEL
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9570 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5842
Mailing Address - Country:US
Mailing Address - Phone:909-980-4775
Mailing Address - Fax:909-980-2396
Practice Address - Street 1:9570 CENTER AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5842
Practice Address - Country:US
Practice Address - Phone:909-980-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist