Provider Demographics
NPI:1508151895
Name:BONIKOWSKI, KIMBERLY (COTAL)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BONIKOWSKI
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45350 DANTE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-5524
Mailing Address - Country:US
Mailing Address - Phone:586-566-6280
Mailing Address - Fax:
Practice Address - Street 1:14145 SIMONE DR
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-3228
Practice Address - Country:US
Practice Address - Phone:586-566-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007400224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant