Healthcare Provider Details

I. General information

NPI: 1316477250
Provider Name (Legal Business Name): STEPHANIE BONILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 W 8TH ST
SAN PEDRO CA
90731-3120
US

IV. Provider business mailing address

1318 N AVALON BLVD
WILMINGTON CA
90744-2639
US

V. Phone/Fax

Practice location:
  • Phone: 310-831-2358
  • Fax:
Mailing address:
  • Phone: 310-549-2710
  • Fax: 310-549-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: