=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295303352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIZA BONILLA VERNE OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2021
-----------------------------------------------------
Last Update Date | 06/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N MILLER DR
-----------------------------------------------------
City | SUNBURY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43074-7646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-913-0132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 342 SAINT ANDREWS DR
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43017-3348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-557-8363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT010886
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------