Provider Demographics
NPI:1417848219
Name:NEURODIVERGENT PSYCHIATRIC SPECIALISTS NURSING
Entity type:Organization
Organization Name:NEURODIVERGENT PSYCHIATRIC SPECIALISTS NURSING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:714-420-9890
Mailing Address - Street 1:2112 E 4TH ST
Mailing Address - Street 2:STE 228A
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3840
Mailing Address - Country:US
Mailing Address - Phone:949-409-6460
Mailing Address - Fax:949-749-7433
Practice Address - Street 1:2112 E 4TH ST
Practice Address - Street 2:STE 228A
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3840
Practice Address - Country:US
Practice Address - Phone:949-409-6460
Practice Address - Fax:949-749-7433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-10
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB540002Medicaid