Provider Demographics
NPI:1669819249
Name:SMITH, BONNIE ANN (MOT, OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:BONNIE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3382 CREEKSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-2848
Mailing Address - Country:US
Mailing Address - Phone:810-285-1094
Mailing Address - Fax:
Practice Address - Street 1:60 PARKHURST DR.
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342
Practice Address - Country:US
Practice Address - Phone:248-451-7545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008032225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist