Basic Information
| Provider Information | |||||||||
| NPI: | 1679112569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONILLA | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | ADAM | ||||||||
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| Credential: | LADC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR STE 321 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 LONG WHARF DR STE 321 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2019 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1359 | CT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 5365 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 004041000 | 05 | CT | MEDICAID | 008003745 | 05 | CT | MEDICAID | 008092656 | 05 | CT | MEDICAID |