Provider Demographics
NPI:1962979997
Name:MITCHELL, BONNIE JEAN
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:MITCHELL
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 1:1010 TURQUOISE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1269
Mailing Address - Country:US
Mailing Address - Phone:303-501-3400
Mailing Address - Fax:
Practice Address - Street 1:1010 TURQUOISE ST STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-1269
Practice Address - Country:US
Practice Address - Phone:303-501-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16844101YP2500X
CALPCC9728101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional