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Organization
NEURODIVERGENT PSYCHIATRIC SPECIALISTS
Active
Organization
NEURODIVERGENT PSYCHIATRIC SPECIALISTS
Active
Other names
Neurodivergent Psychiatric Specialists
Organization subpart
No
Provider details
NPI number
Authorized official
JESSE ANTHONY BONILLA PMHNP (EXECUTIVE OFFICER)
(714) 420-9890
Entity
Organization
Contact information
Practice address
2112 E 4TH ST, STE 228A, SANTA ANA, CA 92705-3840
(949) 409-6460
(949) 749-7433
Mailing address
2112 E 4TH ST STE 228, SANTA ANA, CA 92705-3840
(949) 409-6460
(949) 749-7433
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
2084P0800X
Psychiatry Physician
—
—
208D00000X
General Practice Physician
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
CB540002
—
CA
Enumeration date
07/10/2025
Last updated
12/08/2025
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