Provider Demographics
NPI:1487608220
Name:BLACK, BONNIE SUE (PTA)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:SUE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:BONNIE
Other - Middle Name:SUE
Other - Last Name:SMOTHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3720 QUEEN CT SW
Mailing Address - Street 2:STE. 1
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-4735
Mailing Address - Country:US
Mailing Address - Phone:641-295-3310
Mailing Address - Fax:
Practice Address - Street 1:3720 QUEEN CT SW
Practice Address - Street 2:STE. 1
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-4735
Practice Address - Country:US
Practice Address - Phone:641-295-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00305225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant