Healthcare Provider Details

I. General information

NPI: 1093907917
Provider Name (Legal Business Name): STEVEN BONANNO PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 NEW STATE RD APT F
MANCHESTER CT
06042-7937
US

IV. Provider business mailing address

PO BOX 891
SOUTH WINDSOR CT
06074-0891
US

V. Phone/Fax

Practice location:
  • Phone: 860-539-6779
  • Fax:
Mailing address:
  • Phone: 860-432-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number8741
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number002823
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: