MEDICARE: BONILLA BEHAVIORAL HEALTH, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1295554210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONILLA BEHAVIORAL HEALTH, PLLC

Provider Business Mailing Address
First Line	:	7247 DAZZLE POINT ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-4745
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7247 DAZZLE POINT ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-4745
Country	:	US
Telephone Number	:	323-875-4843
Fax Number	:

Authorized Official
Title or Position	:	OWNER, FOUNDER
Name	:	LEAH BONILLA
Credential	:	PHD, LLP
Telephone Number	:	323-875-4843

Provider Enumeration Date	:	10/07/2024
Last Update Date	:	10/07/2024

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