Provider Demographics
NPI:1891428918
Name:BONILLA, CHRISTOPHER OMAR (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:OMAR
Last Name:BONILLA
Suffix:
Gender:M
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BROOKRUN DR APT 1313
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2944
Mailing Address - Country:US
Mailing Address - Phone:704-648-3473
Mailing Address - Fax:
Practice Address - Street 1:1909 J N PEASE PL STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4509
Practice Address - Country:US
Practice Address - Phone:980-621-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0177521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical