Healthcare Provider Details

I. General information

NPI: 1437320637
Provider Name (Legal Business Name): BETSY I BONILLA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 TREMONT ST
ROXBURY MA
02120-2929
US

IV. Provider business mailing address

108 GLEN ROCK AVE
MALDEN MA
02148-1242
US

V. Phone/Fax

Practice location:
  • Phone: 617-320-2511
  • Fax: 617-622-1086
Mailing address:
  • Phone: 617-320-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number212427
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: