Provider Demographics
NPI:1639221559
Name:BONIECKI, EDWARD ANDREW (OT/L)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ANDREW
Last Name:BONIECKI
Suffix:
Gender:M
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-0171
Mailing Address - Country:US
Mailing Address - Phone:406-273-9038
Mailing Address - Fax:
Practice Address - Street 1:901 SW HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-3600
Practice Address - Country:US
Practice Address - Phone:406-214-2606
Practice Address - Fax:406-213-0073
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT803225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist