Provider Demographics
NPI:1720401987
Name:BONIFACIO, MICHELLE MAE (RPT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE MAE
Middle Name:
Last Name:BONIFACIO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 N CATALINA AVE
Mailing Address - Street 2:APT. 8
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1033
Mailing Address - Country:US
Mailing Address - Phone:626-644-9712
Mailing Address - Fax:
Practice Address - Street 1:550 N CATALINA AVE
Practice Address - Street 2:APT. 8
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1033
Practice Address - Country:US
Practice Address - Phone:626-644-9712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist