Provider Demographics
NPI:1528274826
Name:BONESHO, KATHY J (OT)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:J
Last Name:BONESHO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N79W14749 APPLETON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4375
Mailing Address - Country:US
Mailing Address - Phone:262-253-3750
Mailing Address - Fax:262-253-3776
Practice Address - Street 1:N79W14749 APPLETON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4375
Practice Address - Country:US
Practice Address - Phone:262-253-3750
Practice Address - Fax:262-253-3776
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
WI2194-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40792100Medicaid