Provider Demographics
NPI:1336789312
Name:BONNER, CARILLA R (MS)
Entity Type:Individual
Prefix:
First Name:CARILLA
Middle Name:R
Last Name:BONNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 GROVE WEST BLVD UNIT 410
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-2618
Mailing Address - Country:US
Mailing Address - Phone:832-901-4842
Mailing Address - Fax:
Practice Address - Street 1:5010 GROVE WEST BLVD UNIT 410
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-2618
Practice Address - Country:US
Practice Address - Phone:832-901-4842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist