Basic Information
| Provider Information | |||||||||
| NPI: | 1598278251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONSALL | ||||||||
| FirstName: | THEODORA | ||||||||
| MiddleName: | MAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 OAKMORE RD | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946021833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169499059 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3200 ADELINE ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947032407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106010203 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2017 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.