Provider Demographics
NPI:1699789925
Name:BONAMO, JULIE TESSLER (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:TESSLER
Last Name:BONAMO
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 S CLYDE MORRIS BLVD
Mailing Address - Street 2:ST. 300
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-2300
Mailing Address - Country:US
Mailing Address - Phone:386-258-8080
Mailing Address - Fax:386-258-8177
Practice Address - Street 1:3635 S CLYDE MORRIS BLVD
Practice Address - Street 2:ST. 300
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2300
Practice Address - Country:US
Practice Address - Phone:386-258-8080
Practice Address - Fax:386-258-8177
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT5228225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892520800Medicaid
FLZ7064OtherBLUE CROSS BLUE SHIELD FL
FLU5205AMedicare ID - Type Unspecified