Provider Demographics
NPI:1003341272
Name:BONAGUIDE, MARC (LCSW)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:BONAGUIDE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SUNRISE TER
Mailing Address - Street 2:
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-9755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 SUNRISE TER
Practice Address - Street 2:
Practice Address - City:WEATOGUE
Practice Address - State:CT
Practice Address - Zip Code:06089-9755
Practice Address - Country:US
Practice Address - Phone:860-951-1240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0065481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical