Healthcare Provider Details

I. General information

NPI: 1508394248
Provider Name (Legal Business Name): BONI MAE KNOBLE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BONI MAE SLAGERMAN DPT

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 PRAIRIE AVE
BELOIT WI
53511-2246
US

IV. Provider business mailing address

2737 PRAIRIE AVE
BELOIT WI
53511-2246
US

V. Phone/Fax

Practice location:
  • Phone: 608-299-8181
  • Fax: 608-299-8281
Mailing address:
  • Phone: 608-299-8181
  • Fax: 608-299-8281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: