Provider Demographics
NPI:1093114712
Name:BIVONA, PAT
Entity Type:Individual
Prefix:
First Name:PAT
Middle Name:
Last Name:BIVONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 KATHRYN LN
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5705
Mailing Address - Country:US
Mailing Address - Phone:631-312-0365
Mailing Address - Fax:
Practice Address - Street 1:7 KATHRYN LN
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-5705
Practice Address - Country:US
Practice Address - Phone:631-312-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1249755103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst