Provider Demographics
NPI:1811220445
Name:BONSALL, KATHLEEN S (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:BONSALL
Suffix:
Gender:F
Credentials:PT, DPT
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 416495 SUITE 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-4840
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:200 CAMPBELL DR STE 107
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1067
Practice Address - Country:US
Practice Address - Phone:609-614-3997
Practice Address - Fax:609-531-2385
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01480800225100000X
PAPT020193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist