Healthcare Provider Details

I. General information

NPI: 1043754682
Provider Name (Legal Business Name): SERGIO BONILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

U.S. NMRTC YOKOSUKA
FPO AP
96350
US

IV. Provider business mailing address

2345 FEN VIEW CIR
ISLAND LAKE IL
60042-8822
US

V. Phone/Fax

Practice location:
  • Phone: 315-243-9224
  • Fax:
Mailing address:
  • Phone: 224-325-1276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149026857
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13997
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: