1740530336 NPI number — MRS. KATHERINE I BONILLA LMSW, LADC

Table of content: MRS. KATHERINE I BONILLA LMSW, LADC (NPI 1740530336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740530336 NPI number — MRS. KATHERINE I BONILLA LMSW, LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONILLA
Provider First Name:
KATHERINE
Provider Middle Name:
I
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW, LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740530336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 ASHFORD LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06278-1201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-646-3888
Provider Business Mailing Address Fax Number:
860-645-4132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
872 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIMANTIC
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06226-2342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-985-3494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  010124 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001366 . This is a "MASTER'S LEVEL SOCIAL WORKER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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