Provider Demographics
NPI:1639203797
Name:MARIETTA-GLIPTIS, BONNIE A (PT)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:A
Last Name:MARIETTA-GLIPTIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-2014
Mailing Address - Country:US
Mailing Address - Phone:516-764-0930
Mailing Address - Fax:
Practice Address - Street 1:1770 STILLWELL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-6409
Practice Address - Country:US
Practice Address - Phone:718-652-9790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009478-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist