Provider Demographics
NPI:1780843540
Name:BONANNO, DAVID (PSYD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BONANNO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RESEARCH PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-4214
Mailing Address - Country:US
Mailing Address - Phone:800-370-3651
Mailing Address - Fax:860-510-0030
Practice Address - Street 1:20 RESEARCH PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-4214
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:860-510-0030
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT002860103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical