Provider Demographics
NPI:1699148452
Name:SALLEY, BONNI
Entity type:Individual
Prefix:
First Name:BONNI
Middle Name:
Last Name:SALLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 EVERTS AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-2040
Mailing Address - Country:US
Mailing Address - Phone:518-793-4700
Mailing Address - Fax:
Practice Address - Street 1:52 LAKEVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:LAKE GEORGE
Practice Address - State:NY
Practice Address - Zip Code:12845-6413
Practice Address - Country:US
Practice Address - Phone:518-915-3458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009432-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant