Provider Demographics
NPI:1710562103
Name:BONILLA REYES, GABRIELA GUADALUPE
Entity Type:Individual
Prefix:
First Name:GABRIELA
Middle Name:GUADALUPE
Last Name:BONILLA REYES
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 1:4300 HOLT BLVD SPC 122
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-4109
Mailing Address - Country:US
Mailing Address - Phone:909-212-9402
Mailing Address - Fax:
Practice Address - Street 1:9500 HAVEN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5807
Practice Address - Country:US
Practice Address - Phone:909-980-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2023-10-11
Deactivation Date:2023-09-14
Deactivation Code:
Reactivation Date:2023-09-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst