Provider Demographics
NPI:1063996460
Name:KELLEY, BONNI (CMT)
Entity type:Individual
Prefix:
First Name:BONNI
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 E 1ST ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-7321
Mailing Address - Country:US
Mailing Address - Phone:408-612-8835
Mailing Address - Fax:408-612-3435
Practice Address - Street 1:35 E 1ST ST STE A
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-7321
Practice Address - Country:US
Practice Address - Phone:408-612-8835
Practice Address - Fax:408-612-3435
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist