Provider Demographics
NPI:1740530336
Name:BONILLA, KATHERINE I (LMSW, LADC)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:I
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LMSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 ASHFORD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06278-1201
Mailing Address - Country:US
Mailing Address - Phone:860-646-3888
Mailing Address - Fax:860-645-4132
Practice Address - Street 1:872 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2342
Practice Address - Country:US
Practice Address - Phone:860-985-3494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0101241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001366OtherMASTER'S LEVEL SOCIAL WORKER