Healthcare Provider Details

I. General information

NPI: 1750782900
Provider Name (Legal Business Name): MICHAEL BONOMO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24302 NORTHERN BLVD
DOUGLASTON NY
11362-1150
US

IV. Provider business mailing address

22 BOB-O-LINK LANE
NORTHPORT NY
11768-3305
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-6200
  • Fax:
Mailing address:
  • Phone: 917-837-5922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number021438
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: