Provider Demographics
NPI:1992146914
Name:LINE, EVELYN BONILLA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:BONILLA
Last Name:LINE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:AUBREY
Other - Last Name:BONILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:605 LAKEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3132
Mailing Address - Country:US
Mailing Address - Phone:714-651-1264
Mailing Address - Fax:714-651-1264
Practice Address - Street 1:7812 EDINGER AVE #400
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647
Practice Address - Country:US
Practice Address - Phone:714-916-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP28033235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist