Provider Demographics
NPI:1487176145
Name:MARC BONAGUIDE LLC
Entity type:Organization
Organization Name:MARC BONAGUIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAGUIDE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-951-1240
Mailing Address - Street 1:10 SUNRISE TER
Mailing Address - Street 2:
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-9755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 ALBANY TPKE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:CT
Practice Address - Zip Code:06019-2516
Practice Address - Country:US
Practice Address - Phone:860-951-1240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health