Provider Demographics
NPI:1871649731
Name:HACKER, BONNIE J (MHS, OTRL)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:J
Last Name:HACKER
Suffix:
Gender:F
Credentials:MHS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2517
Mailing Address - Country:US
Mailing Address - Phone:919-928-0204
Mailing Address - Fax:919-928-9423
Practice Address - Street 1:3905 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2517
Practice Address - Country:US
Practice Address - Phone:919-928-0204
Practice Address - Fax:919-928-9423
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC216225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301506Medicaid