Healthcare Provider Details

I. General information

NPI: 1417848219
Provider Name (Legal Business Name): NEURODIVERGENT PSYCHIATRIC SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 E 4TH ST STE 228A
SANTA ANA CA
92705-3840
US

IV. Provider business mailing address

2112 E 4TH ST STE 228
SANTA ANA CA
92705-3840
US

V. Phone/Fax

Practice location:
  • Phone: 949-409-6460
  • Fax: 949-749-7433
Mailing address:
  • Phone: 949-409-6460
  • Fax: 949-749-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSE ANTHONY BONILLA
Title or Position: EXECUTIVE OFFICER
Credential: PMHNP
Phone: 714-420-9890