Provider Demographics
NPI:1871631416
Name:BONILLA, MARTHA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:BONILLA
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 1:394 WHITE ST
Mailing Address - Street 2:APT 31
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-2740
Mailing Address - Country:US
Mailing Address - Phone:973-493-9376
Mailing Address - Fax:
Practice Address - Street 1:309 BLACK OAK RIDGE RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-6504
Practice Address - Country:US
Practice Address - Phone:973-692-9072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01138400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist