Provider Demographics
NPI:1912346149
Name:PRZETACZNIK, BONNIE (OTR)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:PRZETACZNIK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BRONZE POINTE N
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1197
Mailing Address - Country:US
Mailing Address - Phone:618-235-6814
Mailing Address - Fax:618-235-6872
Practice Address - Street 1:15 BRONZE POINTE N
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1197
Practice Address - Country:US
Practice Address - Phone:618-235-6814
Practice Address - Fax:618-235-6872
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.002980225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILILLINOISMedicaid