Provider Demographics
NPI:1790297018
Name:SPEARS, BONNY (PTA)
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:
Last Name:SPEARS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 JESSICA WAY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5852
Mailing Address - Country:US
Mailing Address - Phone:770-905-9077
Mailing Address - Fax:
Practice Address - Street 1:2000 VILLAGE PROFESSIONAL DR STE 300
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8499
Practice Address - Country:US
Practice Address - Phone:678-880-9472
Practice Address - Fax:678-880-9624
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001819225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant