Provider Demographics
NPI:1700278462
Name:BONFIGLIO, COLIN
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:BONFIGLIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 21ST AVE S
Mailing Address - Street 2:SUITE, 9211
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-8590
Mailing Address - Country:US
Mailing Address - Phone:615-936-5040
Mailing Address - Fax:
Practice Address - Street 1:1215 21ST AVE S
Practice Address - Street 2:SUITE, 9211
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-8590
Practice Address - Country:US
Practice Address - Phone:615-936-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3649225X00000X
225XN1300X, 225XR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility