Provider Demographics
NPI:1720328933
Name:BONECK, EVELYN FAYE (LMP)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:FAYE
Last Name:BONECK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 S DAWES ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-2024
Mailing Address - Country:US
Mailing Address - Phone:509-586-2078
Mailing Address - Fax:
Practice Address - Street 1:1911 S DAWES ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-2024
Practice Address - Country:US
Practice Address - Phone:509-586-2078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00021053225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist