Provider Demographics
NPI:1093979148
Name:BONHAM, STEVEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:
Last Name:BONHAM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 NAIL RD
Mailing Address - Street 2:APT B-21
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8853
Mailing Address - Country:US
Mailing Address - Phone:870-897-9503
Mailing Address - Fax:
Practice Address - Street 1:385 NAIL RD
Practice Address - Street 2:APT B-21
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-8853
Practice Address - Country:US
Practice Address - Phone:870-897-9503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2173AR225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant