Provider Demographics
NPI:1871005173
Name:BONILLA, ELISE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 SOUTHPORT DR APT 250
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6806
Mailing Address - Country:US
Mailing Address - Phone:507-828-2305
Mailing Address - Fax:
Practice Address - Street 1:1508 SOUTHPORT DR APT 250
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6806
Practice Address - Country:US
Practice Address - Phone:507-828-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110673235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherN/A