Provider Demographics
NPI:1275593501
Name:BONNER, MARY E (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:BONNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 GANTTOWN RD
Mailing Address - Street 2:SUITE A 3
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080
Mailing Address - Country:US
Mailing Address - Phone:856-589-9014
Mailing Address - Fax:856-582-8220
Practice Address - Street 1:438 GANTTOWN RD
Practice Address - Street 2:SUITE A 3
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080
Practice Address - Country:US
Practice Address - Phone:856-589-9014
Practice Address - Fax:856-582-8220
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA0105300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
087420UDEMedicare ID - Type Unspecified