Provider Demographics
NPI:1083049753
Name:FARESICH, BONNIE J (PT)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:J
Last Name:FARESICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-9328
Mailing Address - Country:US
Mailing Address - Phone:973-615-0210
Mailing Address - Fax:
Practice Address - Street 1:1 CEDAR CREST DR
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-2100
Practice Address - Country:US
Practice Address - Phone:973-831-3670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40 QA00345500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist