=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821648635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTIN BONILLA NEW HOPE COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2019
-----------------------------------------------------
Last Update Date | 09/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3208 WHITNEY AVE
-----------------------------------------------------
City | HAMDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06518-2158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-209-1835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 COSTANZO CT
-----------------------------------------------------
City | HAMDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06518-2464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-209-1835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTIN MARIE BONILLA
-----------------------------------------------------
Credential | MS, LADC, CCS, AADC
-----------------------------------------------------
Telephone | 475-209-1835
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------