Healthcare Provider Details

I. General information

NPI: 1003197930
Provider Name (Legal Business Name): BONNIE JILL WEISSMAN P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 DE SOTO AVE
WOODLAND HILLS CA
91367-6701
US

IV. Provider business mailing address

PO BOX 3627
GRANADA HILLS CA
91394-0627
US

V. Phone/Fax

Practice location:
  • Phone: 818-719-3958
  • Fax:
Mailing address:
  • Phone: 818-368-0619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberAT595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: