Provider Demographics
NPI:1578870143
Name:BONCZEK, ANNETTE (BSPT)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:BONCZEK
Suffix:
Gender:F
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CARA CT
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1085
Mailing Address - Country:US
Mailing Address - Phone:609-204-4849
Mailing Address - Fax:609-653-1258
Practice Address - Street 1:11 CARA CT
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1085
Practice Address - Country:US
Practice Address - Phone:609-204-4849
Practice Address - Fax:609-653-1258
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00696500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA00696500OtherSTATE LICENSE