Provider Demographics
NPI:1063169209
Name:BONDEROV, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:BONDEROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:
Other - Last Name:BONDEROV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8747 NOGAL AVE
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90606-2807
Mailing Address - Country:US
Mailing Address - Phone:562-441-4903
Mailing Address - Fax:
Practice Address - Street 1:8747 NOGAL AVE
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2807
Practice Address - Country:US
Practice Address - Phone:562-441-4903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral