Provider Demographics
NPI:1215034178
Name:DALTON, BONITA FAYE (MS,OTR/L)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:FAYE
Last Name:DALTON
Suffix:
Gender:F
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:BO
Other - Middle Name:
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS,OTR/L
Mailing Address - Street 1:PO BOX 7782
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33586-7782
Mailing Address - Country:US
Mailing Address - Phone:813-505-2518
Mailing Address - Fax:
Practice Address - Street 1:294 W CARLOS AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-1846
Practice Address - Country:US
Practice Address - Phone:928-524-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3109225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ807-208Medicaid