Healthcare Provider Details

I. General information

NPI: 1477387843
Provider Name (Legal Business Name): SESAR JESUS BONILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 VALLEY GROVE DR APT D
LOLO MT
59847-8617
US

IV. Provider business mailing address

2244 E VISTA DR
MISSOULA MT
59803-2620
US

V. Phone/Fax

Practice location:
  • Phone: 406-273-4633
  • Fax:
Mailing address:
  • Phone: 406-208-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number72152
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: