Healthcare Provider Details

I. General information

NPI: 1427533835
Provider Name (Legal Business Name): BON HA GU LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24302 NORTHERN BLVD
LITTLE NECK NY
11362-1150
US

IV. Provider business mailing address

24302 NORTHERN BLVD
LITTLE NECK NY
11362-1199
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number090339
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number097774
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: