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NPI Code Detail

MEDICARE: MRS. ELLEN JEAN BONINE OTRL

MEDICARE: MRS. ELLEN JEAN BONINE OTRL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225XP0200XPediatric Occupational TherapistIL

General Provider Information

NPI Number : 1891849857
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. ELLEN JEAN BONINE OTRL
Provider Business Mailing Address
First Line : 2956 BASE LINE RD
Second Line :
City : KIRKLAND
State : IL
Zip : 60146-8702
Country : US
Telephone Number : 630-408-5845
Fax Number : 630-444-0078
Provider Business Practice Location Address
First Line : 40W310 LAFOX RD UNIT A1
Second Line :
City : ST CHARLES
State : IL
Zip : 60175-6591
Country : US
Telephone Number : 630-444-0077
Fax Number : 630-444-0078
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/23/2007
Last Update Date : 07/08/2007

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