Provider Demographics
NPI:1891849857
Name:BONINE, ELLEN JEAN (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:JEAN
Last Name:BONINE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2956 BASE LINE RD
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60146-8702
Mailing Address - Country:US
Mailing Address - Phone:630-408-5845
Mailing Address - Fax:630-444-0078
Practice Address - Street 1:40W310 LAFOX RD UNIT A1
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6591
Practice Address - Country:US
Practice Address - Phone:630-444-0077
Practice Address - Fax:630-444-0078
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics