MEDICARE: NICOLE BONILLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1033841655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE BONILLA

Provider Business Mailing Address
First Line	:	16500 VENTURA BLVD STE 414
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91436-5050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5901 GREEN VALLEY CIR STE 466
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-6970
Country	:	US
Telephone Number	:	951-455-2447
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2022
Last Update Date	:	08/11/2022

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Directions to “ NICOLE BONILLA ” Practice Location

Language	Start Address	Practice Location

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