Provider Demographics
NPI:1902956089
Name:BONILLA, SARA INES (LMHC, CCM)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:INES
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LMHC, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 9TH ST APT 104
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5139
Mailing Address - Country:US
Mailing Address - Phone:781-816-3130
Mailing Address - Fax:
Practice Address - Street 1:10 CABOT RD STE 205
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5173
Practice Address - Country:US
Practice Address - Phone:781-202-6524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACCM4242685171M00000X
MALMHC7737101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator