Provider Demographics
NPI:1043244478
Name:BURKE, BONNIE JOYCE (PT, MTC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JOYCE
Last Name:BURKE
Suffix:
Gender:F
Credentials:PT, MTC
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:JOYCE
Other - Last Name:BYRNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:605 OLD BALLAS RD STE 128
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7070
Mailing Address - Country:US
Mailing Address - Phone:314-801-8776
Mailing Address - Fax:314-801-8775
Practice Address - Street 1:605 OLD BALLAS RD STE 128
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7070
Practice Address - Country:US
Practice Address - Phone:314-801-8776
Practice Address - Fax:314-801-8775
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070002879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00150036OtherRR MEDICARE
ILK06099Medicare PIN