Provider Demographics
NPI:1194068080
Name:BUONOMO, MICHAEL ANGELO I (MSED,PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANGELO
Last Name:BUONOMO
Suffix:I
Gender:M
Credentials:MSED,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 NESCONSET HWY
Mailing Address - Street 2:5225 NESCONSET HWY
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2053
Mailing Address - Country:US
Mailing Address - Phone:631-473-4284
Mailing Address - Fax:631-331-2204
Practice Address - Street 1:5225 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-473-4284
Practice Address - Fax:631-331-2204
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1702281101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health