Provider Demographics
NPI:1003612375
Name:BONGORNO, SASHA N
Entity type:Individual
Prefix:
First Name:SASHA
Middle Name:N
Last Name:BONGORNO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1619
Mailing Address - Country:US
Mailing Address - Phone:216-212-5856
Mailing Address - Fax:
Practice Address - Street 1:10861 YANKEE ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3574
Practice Address - Country:US
Practice Address - Phone:216-212-5856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health