Provider Demographics
NPI:1700865136
Name:BONACCI, JUSTIN J (PT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:J
Last Name:BONACCI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3420
Mailing Address - Country:US
Mailing Address - Phone:631-467-4235
Mailing Address - Fax:631-467-2655
Practice Address - Street 1:1636 MONTAUK HWY
Practice Address - Street 2:STE 4
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-3016
Practice Address - Country:US
Practice Address - Phone:631-399-0007
Practice Address - Fax:631-399-2992
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017345-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist