Provider Demographics
NPI:1093967317
Name:MITCHELL, BONITA ANN (MASSAGE THERAPIST MT)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:ANN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 13412
Mailing Address - Street 2:235 RUBY DR. CREATIVE MOVEMENT WORKSHOP
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208
Mailing Address - Country:US
Mailing Address - Phone:478-755-8844
Mailing Address - Fax:478-746-7217
Practice Address - Street 1:235 RUBY DR.
Practice Address - Street 2:CREATIVE MOVEMENT WORKSHOP
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31208
Practice Address - Country:US
Practice Address - Phone:478-755-8844
Practice Address - Fax:478-746-7217
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT001093225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist