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General NPI Number Information
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NPI Number | 1346671641
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Entity Type | Individual
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Provider Name | MS. MARIE ANTONETTE BALDERAMA BONGALONTA
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Gender | Female
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Dates
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Enumeration Date | 12/11/2013
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Last Update Date | 12/11/2013
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Provider Practice Location Address
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Address Line | 1580 SAWGRASS CORPORATE PKWY SUITE 100
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City | SUNRISE
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State | FL
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Zip | 33323-2859
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Country | US
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Telephone | 312-608-8211
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Fax |
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Provider Business Mailing Address
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Address Line | 1580 SAWGRASS CORPORATE PKWY SUITE 100
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City | SUNRISE
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State | FL
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Zip | 33323-2859
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Country | US
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Telephone | 312-608-8211
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1229668
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070020367
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 009965
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License Number State | CT
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Taxonomy #4
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1258924
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License Number State | WI
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