Provider Demographics
NPI:1780358705
Name:SMITH-MARINO, BONNIE MARIE (COTA/L)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:MARIE
Last Name:SMITH-MARINO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9521 DURANGO WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1905
Mailing Address - Country:US
Mailing Address - Phone:916-509-6825
Mailing Address - Fax:
Practice Address - Street 1:5270 ELVAS AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-2332
Practice Address - Country:US
Practice Address - Phone:916-346-9352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5622224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant