Provider Demographics
NPI:1336497270
Name:BONAVITA, ANTHONY PAUL
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:PAUL
Last Name:BONAVITA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23044
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93121-3044
Mailing Address - Country:US
Mailing Address - Phone:805-708-3346
Mailing Address - Fax:
Practice Address - Street 1:1227 DE LA VINA ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-3129
Practice Address - Country:US
Practice Address - Phone:805-708-3346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31286103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical