Provider Demographics
NPI:1366640518
Name:BONILLA, TARA TERINA (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:TERINA
Last Name:BONILLA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3638
Mailing Address - Country:US
Mailing Address - Phone:859-779-3529
Mailing Address - Fax:
Practice Address - Street 1:1740 FOREST LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3638
Practice Address - Country:US
Practice Address - Phone:859-779-3529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3546225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist