Healthcare Provider Details

I. General information

NPI: 1982204467
Provider Name (Legal Business Name): LARINA NOELLE BONGARD BS, RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 09/18/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 HILLANDALE DR STE 100
LITHONIA GA
30058-4842
US

IV. Provider business mailing address

2008 EASTVIEW PKWY STE 200, CONYERS, GA 30013
CONYERS GA
30013
US

V. Phone/Fax

Practice location:
  • Phone: 470-361-2976
  • Fax:
Mailing address:
  • Phone: 648-905-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-135627
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: