Provider Demographics
NPI:1174004931
Name:MAUPPIN, BONNIE D (PTA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:D
Last Name:MAUPPIN
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 1:3754 COUNTY ROAD 2225
Mailing Address - Street 2:
Mailing Address - City:IVANHOE
Mailing Address - State:TX
Mailing Address - Zip Code:75447-4131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 SEVEN OAKS RD
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-3237
Practice Address - Country:US
Practice Address - Phone:903-583-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2035087225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant