Provider Demographics
NPI:1558035105
Name:HIBBARD, BONNY (COTA)
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:
Last Name:HIBBARD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-2602
Mailing Address - Country:US
Mailing Address - Phone:321-368-2350
Mailing Address - Fax:
Practice Address - Street 1:8020 RIVER STONE DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-8761
Practice Address - Country:US
Practice Address - Phone:540-834-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002173224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant