Healthcare Provider Details

I. General information

NPI: 1235906645
Provider Name (Legal Business Name): BONAVITACOLA PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2023
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 BETHLEHEM PIKE STE 201
FLOURTOWN PA
19031-1946
US

IV. Provider business mailing address

6711 GERMANTOWN AVE UNIT 25281
PHILADELPHIA PA
19119-2187
US

V. Phone/Fax

Practice location:
  • Phone: 973-932-0125
  • Fax:
Mailing address:
  • Phone: 973-932-0125
  • 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: LAUREN BONAVITACOLA
Title or Position: OWNER
Credential:
Phone: 973-932-0125