Provider Demographics
NPI:1164990461
Name:BONACUM, TIMOTHY PATRICK (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:BONACUM
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-817-7848
Practice Address - Street 1:7910 BEECHMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-4210
Practice Address - Country:US
Practice Address - Phone:513-232-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT020936225100000X
MI26010022882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist