Provider Demographics
NPI:1538936521
Name:BONILLA, PRIMO (OTR/L, HT, PAM)
Entity type:Individual
Prefix:
First Name:PRIMO
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:OTR/L, HT, PAM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 9TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6248
Mailing Address - Country:US
Mailing Address - Phone:707-232-5452
Mailing Address - Fax:707-306-7112
Practice Address - Street 1:670 9TH ST STE 4
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6248
Practice Address - Country:US
Practice Address - Phone:707-232-5452
Practice Address - Fax:707-306-7112
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24672225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist