Provider Demographics
NPI:1104076629
Name:BONILHA, HEATHER SHAW (PHD CCC-SLP)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:SHAW
Last Name:BONILHA
Suffix:
Gender:F
Credentials:PHD CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 SAINT JULIAN PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2407
Mailing Address - Country:US
Mailing Address - Phone:803-777-2614
Mailing Address - Fax:
Practice Address - Street 1:1601 SAINT JULIAN PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2407
Practice Address - Country:US
Practice Address - Phone:803-777-2614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3483235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426521Medicaid
SC426521Medicaid