Basic Information
| Provider Information | |||||||||
| NPI: | 1164164364 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONNIE MONDRAGON COUNSELING, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 N GORDON ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | ALVIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775112373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815850000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 N GORDON ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | ALVIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775112373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815850000 | ||||||||
| FaxNumber: | 2815850080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2022 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | MONDRAGON | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2815850000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MS, LPC-S, RPT-S | ||||||||
| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 343966301 | 05 | TX | MEDICAID |