Healthcare Provider Details

I. General information

NPI: 1669270807
Provider Name (Legal Business Name): BONNY JEAN SKOLNIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 SPRING ST
LA MESA CA
91942-0263
US

IV. Provider business mailing address

8030 LA MESA BLVD STE 25
LA MESA CA
91942-0335
US

V. Phone/Fax

Practice location:
  • Phone: 619-782-0700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-415268
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: