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General NPI Number Information
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NPI Number | 1407210784
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Entity Type | Individual
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Provider Name | DANIELA ALEJANDRA BONILLA BERMUDEZ LADC
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Gender | Female
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Dates
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Enumeration Date | 04/12/2016
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Last Update Date | 04/12/2016
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Provider Practice Location Address
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Address Line | 6200 EXCELSIOR BLVD STE 203
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-2734
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Country | US
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Telephone | 952-548-9354
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Fax | 952-925-3264
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Provider Business Mailing Address
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Address Line | 6200 EXCELSIOR BLVD STE 203
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-2734
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Country | US
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Telephone | 952-548-9354
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Fax | 952-925-3264
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 304119
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License Number State | MN
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