Provider Demographics
NPI:1285392415
Name:BONILLA, NICOLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 EAGLE CREST DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-1215
Mailing Address - Country:US
Mailing Address - Phone:214-704-5483
Mailing Address - Fax:
Practice Address - Street 1:200 S DENTON TAP RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-3270
Practice Address - Country:US
Practice Address - Phone:214-496-6932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103555235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist