Provider Demographics
NPI:1982204467
Name:BONGARD, LARINA NOELLE (BS, RBT)
Entity Type:Individual
Prefix:
First Name:LARINA
Middle Name:NOELLE
Last Name:BONGARD
Suffix:
Gender:F
Credentials:BS, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5461 HILLANDALE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4842
Mailing Address - Country:US
Mailing Address - Phone:470-361-2976
Mailing Address - Fax:
Practice Address - Street 1:5461 HILLANDALE DR STE 100
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4842
Practice Address - Country:US
Practice Address - Phone:470-361-2976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-135627106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician