Provider Demographics
NPI:1790185551
Name:BONIFAS, ANGIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:BONIFAS
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:PO BOX 176
Mailing Address - Street 2:202 N CHERRY ST
Mailing Address - City:PAULDING
Mailing Address - State:OH
Mailing Address - Zip Code:45833
Mailing Address - Country:US
Mailing Address - Phone:419-399-4711
Mailing Address - Fax:
Practice Address - Street 1:202 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879-1211
Practice Address - Country:US
Practice Address - Phone:419-399-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003093225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics