Healthcare Provider Details

I. General information

NPI: 1356622096
Provider Name (Legal Business Name): CARLY ALISSA BONNELL M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DR DEPT 680
LA JOLLA CA
92093-0680
US

IV. Provider business mailing address

9500 GILMAN DR DEPT 680
LA JOLLA CA
92093-0680
US

V. Phone/Fax

Practice location:
  • Phone: 858-534-2812
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW61140
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: