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General NPI Number Information
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NPI Number | 1770257297
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Entity Type | Individual
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Provider Name | MR. BONN DEMETRIO MISO HIDALGO III
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Gender | Male
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Dates
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Enumeration Date | 08/07/2021
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Last Update Date | 06/20/2023
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Provider Practice Location Address
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Address Line | 4760 SEPULVEDA BLVD
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City | CULVER CITY
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State | CA
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Zip | 90230-4820
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Country | US
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Telephone | 310-390-6612
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Fax | 310-398-5690
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Provider Business Mailing Address
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Address Line | 15259 ADAMS DR
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City | BALDWIN PARK
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State | CA
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Zip | 91706-3404
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Country | US
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Telephone | 626-991-4385
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 109311
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License Number State | CA
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