Provider Demographics
NPI:1750636627
Name:KOCH, BONNIE DE LANE (OTR/L)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:DE LANE
Last Name:KOCH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13420 W SAN PABLO DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-6818
Mailing Address - Country:US
Mailing Address - Phone:719-237-2649
Mailing Address - Fax:
Practice Address - Street 1:13420 W SAN PABLO DR
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-6818
Practice Address - Country:US
Practice Address - Phone:719-237-2649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5116225XP0200X
CO1054225XP0200X
HI1081225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics