Provider Demographics
NPI:1225144876
Name:GRACE, BONNIE M (RPT)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:M
Last Name:GRACE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86339-0334
Mailing Address - Country:US
Mailing Address - Phone:928-282-2520
Mailing Address - Fax:928-282-2895
Practice Address - Street 1:210 S SUNSET DR
Practice Address - Street 2:STE B
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5406
Practice Address - Country:US
Practice Address - Phone:928-282-2520
Practice Address - Fax:928-282-2895
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6015261QP2000X
CO3435261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy