Provider Demographics
NPI:1861007460
Name:HEAD, BONITA (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:HEAD
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7916 MANDREL WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-9503
Mailing Address - Country:US
Mailing Address - Phone:919-522-5882
Mailing Address - Fax:
Practice Address - Street 1:7916 MANDREL WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-9503
Practice Address - Country:US
Practice Address - Phone:919-522-5882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC04956225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist