Provider Demographics
NPI:1093359564
Name:BONAVISO, LISA MARIA
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIA
Last Name:BONAVISO
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 1:12 FAWN LN
Mailing Address - Street 2:
Mailing Address - City:ARMONK
Mailing Address - State:NY
Mailing Address - Zip Code:10504-1126
Mailing Address - Country:US
Mailing Address - Phone:914-471-5516
Mailing Address - Fax:
Practice Address - Street 1:280 N CENTRAL AVE STE 309
Practice Address - Street 2:
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-1839
Practice Address - Country:US
Practice Address - Phone:914-471-5516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011641101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA