Provider Demographics
NPI:1336723477
Name:BONAFEDE, KAELA
Entity Type:Individual
Prefix:
First Name:KAELA
Middle Name:
Last Name:BONAFEDE
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:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-0243
Mailing Address - Country:US
Mailing Address - Phone:760-541-9693
Mailing Address - Fax:
Practice Address - Street 1:1612 1ST ST
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1407
Practice Address - Country:US
Practice Address - Phone:760-398-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120388106H00000X
106H00000X
CA133863106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist