Provider Demographics
NPI:1326363490
Name:BONACUM, LIZBETH DARIA (PT)
Entity Type:Individual
Prefix:MS
First Name:LIZBETH
Middle Name:DARIA
Last Name:BONACUM
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 1:1915 COUNTY HIGHWAY 6
Mailing Address - Street 2:PO BOX 3
Mailing Address - City:BOVINA CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13740
Mailing Address - Country:US
Mailing Address - Phone:607-832-4880
Mailing Address - Fax:
Practice Address - Street 1:1915 COUNTY HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:BOVINA CENTER
Practice Address - State:NY
Practice Address - Zip Code:13740
Practice Address - Country:US
Practice Address - Phone:607-832-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006052-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist