Provider Demographics
NPI:1528175163
Name:VAN DE MARK, BONNIE LORRAINE (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:LORRAINE
Last Name:VAN DE MARK
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:LORRAINE
Other - Last Name:SINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L, CHT
Mailing Address - Street 1:5803 NEAL AVE N
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2177
Mailing Address - Country:US
Mailing Address - Phone:651-439-8807
Mailing Address - Fax:651-439-0232
Practice Address - Street 1:5803 NEAL AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-2177
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:651-439-0232
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101090225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist