Basic Information
| Provider Information | |||||||||
| NPI: | 1528080553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONITA HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6333 TELEGRAPH AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109231099 | ||||||||
| FaxNumber: | 5109230894 | ||||||||
| Practice Location | |||||||||
| Address1: | 6333 TELEGRAPH AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109231099 | ||||||||
| FaxNumber: | 5109230894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ORTIZ | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | RUBIN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5109231099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | CA | X | Agencies | Case Management | 320800000X | CA | X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.