Provider Demographics
NPI:1760505424
Name:BERG, BONNIE LEE (COTA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:LEE
Last Name:BERG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 TEAL RD
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-3206
Mailing Address - Country:US
Mailing Address - Phone:856-223-1029
Mailing Address - Fax:
Practice Address - Street 1:261 CONNECTICUT DR STE 5
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4177
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09048300224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant