Provider Demographics
NPI:1457714743
Name:BOONSTRA, ANITA M (OT)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:M
Last Name:BOONSTRA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 COFFEE ROAD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2704
Mailing Address - Country:US
Mailing Address - Phone:209-549-4626
Mailing Address - Fax:209-549-4625
Practice Address - Street 1:1917 COFFEE ROAD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2704
Practice Address - Country:US
Practice Address - Phone:209-549-4626
Practice Address - Fax:209-549-4625
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12032225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist