Provider Demographics
NPI:1598311854
Name:HOM, BONITA
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:HOM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 BENITO AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-9101
Mailing Address - Country:US
Mailing Address - Phone:650-248-7786
Mailing Address - Fax:
Practice Address - Street 1:3460 TORRANCE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5812
Practice Address - Country:US
Practice Address - Phone:310-371-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 171M00000X
CA24326225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator