Provider Demographics
NPI:1356830210
Name:BONILLA BONILLA, NELLY ESTHER (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:NELLY
Middle Name:ESTHER
Last Name:BONILLA BONILLA
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 FOREST EDGE DR
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-4502
Mailing Address - Country:US
Mailing Address - Phone:612-475-0505
Mailing Address - Fax:
Practice Address - Street 1:863 FOREST EDGE DR
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-4502
Practice Address - Country:US
Practice Address - Phone:612-475-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRLP6839103T00000X
PR6719103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist