Provider Demographics
NPI:1235344912
Name:BONITA HOUSE, INC.
Entity type:Organization
Organization Name:BONITA HOUSE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:EVON
Authorized Official - Last Name:WEISSBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:510-593-1950
Mailing Address - Street 1:2640 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-3238
Mailing Address - Country:US
Mailing Address - Phone:510-899-7445
Mailing Address - Fax:510-647-9408
Practice Address - Street 1:1410 BONITA AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1909
Practice Address - Country:US
Practice Address - Phone:510-526-4765
Practice Address - Fax:510-526-2887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BONITA HOUSE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-14
Last Update Date:2024-12-24
Deactivation Date:2023-03-17
Deactivation Code:
Reactivation Date:2023-07-24
Provider Licenses
StateLicense IDTaxonomies
CA81491251S00000X
CA81492251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81493Medicaid
CA81491Medicaid
CA81492Medicaid