Provider Demographics
NPI:1376067322
Name:BONSELAAR, MARY ALICE MCBURNEY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARY ALICE
Middle Name:MCBURNEY
Last Name:BONSELAAR
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARY ALICE
Other - Middle Name:WALKER
Other - Last Name:MCBURNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:302 PERIMETER CTR N APT 2154
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-2493
Mailing Address - Country:US
Mailing Address - Phone:404-625-2189
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3390
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:678-377-2882
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist