Provider Demographics
NPI:1285909986
Name:NELSON, BONITA RAE (LMFT)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:RAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:16169 W SUNSET BLVD
Mailing Address - Street 2:203
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3455
Mailing Address - Country:US
Mailing Address - Phone:310-230-2937
Mailing Address - Fax:
Practice Address - Street 1:12316 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3802
Practice Address - Country:US
Practice Address - Phone:310-402-2229
Practice Address - Fax:310-390-3955
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 50542106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist