Healthcare Provider Details

I. General information

NPI: 1942160114
Provider Name (Legal Business Name): MICHAEL BONOMO PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 MIDDLE NECK RD STE 220
GREAT NECK NY
11021-1218
US

IV. Provider business mailing address

134 MIDDLE NECK RD STE 220
GREAT NECK NY
11021-1218
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BONOMO
Title or Position: OWNER
Credential:
Phone: 917-837-5922