Provider Demographics
NPI:1629376900
Name:BONGE, ANDRE (OT)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:BONGE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 HICKMAN MILLS DR
Mailing Address - Street 2:BUILDING II
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64137-1618
Mailing Address - Country:US
Mailing Address - Phone:816-501-5138
Mailing Address - Fax:816-777-0626
Practice Address - Street 1:10330 HICKMAN MILLS DR
Practice Address - Street 2:BUILDING II
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64137-1618
Practice Address - Country:US
Practice Address - Phone:816-501-5138
Practice Address - Fax:816-777-0626
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005089225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist