Provider Demographics
NPI:1376833590
Name:BOENECKE, TIRA JANETTE (MOTR/L)
Entity type:Individual
Prefix:
First Name:TIRA
Middle Name:JANETTE
Last Name:BOENECKE
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 FORBES ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6101 HEALTH CENTER LANE
Practice Address - Street 2:CARRIAGE HILL HEALTH AND REHAB
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407
Practice Address - Country:US
Practice Address - Phone:540-785-1103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005278225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist