Basic Information
| Provider Information | |||||||||
| NPI: | 1639797384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONILLA | ||||||||
| FirstName: | RODOLFO | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2252 SAMUEL COLT CT | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012436933 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 ROUND VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356550926 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2020 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 11275783-3502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.