Provider Demographics
NPI:1093834962
Name:GORE, BONNIE S (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:S
Last Name:GORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E STATE HIGHWAY 121
Mailing Address - Street 2:SUITE 600
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-7942
Mailing Address - Country:US
Mailing Address - Phone:972-745-7500
Mailing Address - Fax:972-471-0700
Practice Address - Street 1:645 E STATE HIGHWAY 121
Practice Address - Street 2:SUITE 600
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-7942
Practice Address - Country:US
Practice Address - Phone:972-745-1500
Practice Address - Fax:972-471-0700
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2002598225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist