Provider Demographics
NPI:1063731867
Name:BONAWITZ, TERESA LYN (LMP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYN
Last Name:BONAWITZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13306 NE 92ND ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-3051
Mailing Address - Country:US
Mailing Address - Phone:360-260-0082
Mailing Address - Fax:
Practice Address - Street 1:9104 NE HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8925
Practice Address - Country:US
Practice Address - Phone:360-773-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60042214172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist