Healthcare Provider Details

I. General information

NPI: 1902956089
Provider Name (Legal Business Name): SARA INES BONILLA LMHC, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CABOT RD STE 205
MEDFORD MA
02155-5173
US

IV. Provider business mailing address

22 9TH ST APT 104
MEDFORD MA
02155-5139
US

V. Phone/Fax

Practice location:
  • Phone: 781-202-6524
  • Fax:
Mailing address:
  • Phone: 781-816-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCCM4242685
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC7737
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: