Provider Demographics
NPI:1316477250
Name:BONILLA, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BONILLA
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 1:1318 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-2639
Mailing Address - Country:US
Mailing Address - Phone:310-549-2710
Mailing Address - Fax:310-549-2715
Practice Address - Street 1:590 W 8TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3120
Practice Address - Country:US
Practice Address - Phone:310-831-2358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103TA0400X
CA7561101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6197-RMedicaid