Provider Demographics
NPI:1922384999
Name:BONILLA, XAVIER ANTONIO (PHD)
Entity type:Individual
Prefix:MR
First Name:XAVIER
Middle Name:ANTONIO
Last Name:BONILLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6290
Mailing Address - Country:US
Mailing Address - Phone:301-381-4586
Mailing Address - Fax:240-563-0460
Practice Address - Street 1:4 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6290
Practice Address - Country:US
Practice Address - Phone:301-381-4586
Practice Address - Fax:240-563-0460
Is Sole Proprietor?:No
Enumeration Date:2011-10-22
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07314103T00000X
MDLC4176101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health