Provider Demographics
NPI:1508649641
Name:BOONSTRA, BEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:BOONSTRA
Suffix:
Gender:M
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 1:119 E PASSAIC ST
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-1342
Mailing Address - Country:US
Mailing Address - Phone:201-880-7787
Mailing Address - Fax:
Practice Address - Street 1:119 E PASSAIC ST
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1342
Practice Address - Country:US
Practice Address - Phone:201-880-7787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01135800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist