Provider Demographics
NPI:1407359938
Name:BONILLA, OLESYA
Entity type:Individual
Prefix:
First Name:OLESYA
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 1:1351 TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-5248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1123 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3681
Practice Address - Country:US
Practice Address - Phone:916-729-3098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-11
Last Update Date:2018-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000000000Medicaid