Basic Information
| Provider Information | |||||||||
| NPI: | 1821424375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONNEVILLE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6310 SAN VICENTE BLVD STE 360 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900485448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238706161 | ||||||||
| FaxNumber: | 5106536475 | ||||||||
| Practice Location | |||||||||
| Address1: | 6310 SAN VICENTE BLVD STE 360 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900485448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238706161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 363LP0808X | 22278 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 1821424375 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.