Healthcare Provider Details

I. General information

NPI: 1700720034
Provider Name (Legal Business Name): TINA R BONAVITA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA RENE BOUSQUET

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 FRANK B MURRAY ST
SPRINGFIELD MA
01103-1106
US

IV. Provider business mailing address

84 WOODSLEY RD
LONGMEADOW MA
01106-2517
US

V. Phone/Fax

Practice location:
  • Phone: 413-301-6019
  • Fax: 413-363-2857
Mailing address:
  • Phone: 413-530-6415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPTL16090
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: