Provider Demographics
NPI:1114212529
Name:BONAGURA, STACEY ANN (SLP)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANN
Last Name:BONAGURA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 OAK RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WEST HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10604-1128
Mailing Address - Country:US
Mailing Address - Phone:914-714-9100
Mailing Address - Fax:
Practice Address - Street 1:6 OAK RIDGE CT
Practice Address - Street 2:
Practice Address - City:WEST HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10604-1128
Practice Address - Country:US
Practice Address - Phone:914-714-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005783235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist