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Provider Information for 1730628363


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BONAVY SOM-KEO


Sex: Female

NPI: 1730628363
Last Updated: 2024-07-24
Certification Date: 2024-07-24

Details

NameValue
NPI1730628363
Enumeration Date2017-02-15
NPI TypeNPI-1 Individual
Sole ProprietorYES
StatusActive
Mailing Address 14112 S KINGSLEY DR
GARDENA, CA 90249-3018
United States

Phone: 310-217-7312 | Fax:
 
Primary Practice Address 14112 S KINGSLEY DR
GARDENA, CA 90249-3018
United States

Phone: 310-217-7312 | Fax:
 
Secondary Practice Address(es)

18350 MOUNT LANGLEY ST
SUITE 140
FOUNTAIN VALLEY, CA 92708-6900
United States

Phone: 714-450-4118 | Fax:714-378-2631
 

Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 101YM0800X - Counselor - Mental Health
No 106H00000X - Marriage & Family Therapist
Yes 106H00000X - Marriage & Family Therapist CA145519