MEDICARE: MS. LIZZETTE BONILLA SW- L.M.S.W.

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	104100000X	Social Worker	069910	NY

General Provider Information

NPI Number	:	1548324882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LIZZETTE BONILLA SW- L.M.S.W.

Provider Business Mailing Address
First Line	:	337 SOUTH AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10303-1408
Country	:	US
Telephone Number	:	718-477-5054
Fax Number	:

Provider Business Practice Location Address
First Line	:	657 CASTLETON AVE.
Second Line	:	SIMHS
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-1408
Country	:	US
Telephone Number	:	718-448-9775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	02/03/2010

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