Provider Demographics
NPI:1063569291
Name:BONAVITA, NEIL J (LCSW)
Entity type:Individual
Prefix:MR
First Name:NEIL
Middle Name:J
Last Name:BONAVITA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 FERN AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-1918
Mailing Address - Country:US
Mailing Address - Phone:215-977-8282
Mailing Address - Fax:
Practice Address - Street 1:1601 WALNUT ST STE 808
Practice Address - Street 2:SUITE 808
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2905
Practice Address - Country:US
Practice Address - Phone:215-977-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0128541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical