Provider Demographics
NPI:1265978035
Name:CARRASQUILLO BONANO, OTONIEL (MA, MED (C))
Entity type:Individual
Prefix:PROF
First Name:OTONIEL
Middle Name:
Last Name:CARRASQUILLO BONANO
Suffix:
Gender:M
Credentials:MA, MED (C)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BRECK ST UNIT 1B
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2839
Mailing Address - Country:US
Mailing Address - Phone:787-391-9851
Mailing Address - Fax:
Practice Address - Street 1:16 BRECK ST UNIT 1B
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2839
Practice Address - Country:US
Practice Address - Phone:787-391-9851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor