Healthcare Provider Details

I. General information

NPI: 1528080553
Provider Name (Legal Business Name): BONITA HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date: 03/17/2023
Reactivation Date: 05/02/2023

III. Provider practice location address

1410 BONITA AVE
BERKELEY CA
94709-1909
US

IV. Provider business mailing address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

V. Phone/Fax

Practice location:
  • Phone: 510-899-7445
  • Fax: 510-647-9408
Mailing address:
  • Phone: 510-714-0996
  • Fax: 510-647-9408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number011400072
License Number StateCA

VIII. Authorized Official

Name: LAURA EVON WEISSBERGER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 510-593-1950