Provider Demographics
NPI:1962297093
Name:BONOMO, LAURIE ANN (LMSW)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ANN
Last Name:BONOMO
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 BIRCHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3603
Mailing Address - Country:US
Mailing Address - Phone:631-835-3172
Mailing Address - Fax:
Practice Address - Street 1:405 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1651
Practice Address - Country:US
Practice Address - Phone:631-240-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125112104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker