Healthcare Provider Details

I. General information

NPI: 1033203088
Provider Name (Legal Business Name): BONEH G AVIDOR PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CIRCLE DR
SHOREHAM NY
11786-1321
US

IV. Provider business mailing address

10 CIRCLE DR
SHOREHAM NY
11786-1321
US

V. Phone/Fax

Practice location:
  • Phone: 631-744-3458
  • Fax:
Mailing address:
  • Phone: 631-744-3458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number013307-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: