=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306641014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LITZY JAQUELINE BONILLA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2025
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1664 MARKET PLACE BLVD
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-7927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-253-4121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2547 LENOX DR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30507-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-540-5934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | 060144168
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------