Provider Demographics
NPI:1023528114
Name:SMITH, BONITA LOUISE
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323A E PALMDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4957
Mailing Address - Country:US
Mailing Address - Phone:661-223-3847
Mailing Address - Fax:661-537-2937
Practice Address - Street 1:2323A E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4957
Practice Address - Country:US
Practice Address - Phone:213-215-6568
Practice Address - Fax:661-537-2937
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 172V00000X
CA104580104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO$$$$$$$$$Medicaid