Provider Demographics
NPI:1639709785
Name:MEYER, BONNIE LUCILLE (PTA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:LUCILLE
Last Name:MEYER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 PORTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-3501
Mailing Address - Country:US
Mailing Address - Phone:574-272-9100
Mailing Address - Fax:
Practice Address - Street 1:3016 PORTAGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-3501
Practice Address - Country:US
Practice Address - Phone:574-272-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004025A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant