Healthcare Provider Details

I. General information

NPI: 1881967354
Provider Name (Legal Business Name): BONNIE KOBAK CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 E 11TH ST
NEW YORK NY
10003-6811
US

IV. Provider business mailing address

80 E 11TH ST
NEW YORK NY
10003-6811
US

V. Phone/Fax

Practice location:
  • Phone: 212-353-8636
  • Fax:
Mailing address:
  • Phone: 212-353-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number022059R
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: