Healthcare Provider Details

I. General information

NPI: 1912564543
Provider Name (Legal Business Name): CORY J BONGIVENGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 E PARK AVE
NILES OH
44446-2352
US

IV. Provider business mailing address

487 JUDITH LN
STRUTHERS OH
44471-1215
US

V. Phone/Fax

Practice location:
  • Phone: 330-544-8005
  • Fax:
Mailing address:
  • Phone: 330-717-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2506704-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: