Healthcare Provider Details

I. General information

NPI: 1255695110
Provider Name (Legal Business Name): BERONICA BONILLA LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 09/27/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 SOLAREX CT UNIT 201
FREDERICK MD
21703-8655
US

IV. Provider business mailing address

6501 NORTH CHARLES ST. CREDENTIALING-CARLA CASH
TOWSON MD
21204-6819
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-8263
  • Fax: 301-682-5326
Mailing address:
  • Phone: 443-761-5294
  • Fax: 434-420-9454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18092
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: