Healthcare Provider Details

I. General information

NPI: 1992631410
Provider Name (Legal Business Name): NICCOLO ANTHONY BONOMO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 E CONGRESS PKWY
CRYSTAL LAKE IL
60014-6202
US

IV. Provider business mailing address

8201 S CASS AVE
DARIEN IL
60561-5314
US

V. Phone/Fax

Practice location:
  • Phone: 779-284-0347
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: