Provider Demographics
NPI:1700066248
Name:QUACKENBUSH, BONNIE RAY (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:RAY
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:JOHNSON
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,CCC-SLP
Mailing Address - Street 1:4705 CHATHAM WAY
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-3492
Mailing Address - Country:US
Mailing Address - Phone:717-657-0311
Mailing Address - Fax:
Practice Address - Street 1:4705 CHATHAM WAY
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-3492
Practice Address - Country:US
Practice Address - Phone:717-657-0311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL004967L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist