Provider Demographics
NPI:1437302239
Name:BONANNO, REBECCA (LCSW)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:BONANNO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 BAYBERRY DR.
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-421-1959
Mailing Address - Fax:
Practice Address - Street 1:140 E MAIN ST
Practice Address - Street 2:11A
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2863
Practice Address - Country:US
Practice Address - Phone:631-421-1959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069358-1104100000X
NY0793111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker