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General NPI Number Information
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NPI Number | 1639797384
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Entity Type | Individual
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Provider Name | RODOLFO STEVEN BONILLA CSW
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Gender | Male
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Dates
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Enumeration Date | 07/09/2020
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Last Update Date | 07/09/2020
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Provider Practice Location Address
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Address Line | 750 ROUND VALLEY DR
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City | PARK CITY
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State | UT
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Zip | 84060-7548
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Country | US
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Telephone | 435-655-0926
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Fax |
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Provider Business Mailing Address
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Address Line | 2252 SAMUEL COLT CT
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City | PARK CITY
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State | UT
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Zip | 84060-7423
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Country | US
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Telephone | 801-243-6933
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Fax |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 11275783-3502
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License Number State | UT
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