Provider Demographics
NPI:1548653587
Name:BONAVITACOLA, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BONAVITACOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 HADDON AVE UNIT 481
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-8024
Mailing Address - Country:US
Mailing Address - Phone:973-932-0125
Mailing Address - Fax:
Practice Address - Street 1:970 HADDON AVE UNIT 481
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-8024
Practice Address - Country:US
Practice Address - Phone:973-932-0125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021710103TB0200X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent