Provider Demographics
NPI:1861225815
Name:BONETA, DESTINY M
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:M
Last Name:BONETA
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 1:9624 S CICERO AVE # 341
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3138
Mailing Address - Country:US
Mailing Address - Phone:708-759-1770
Mailing Address - Fax:
Practice Address - Street 1:9624 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3138
Practice Address - Country:US
Practice Address - Phone:708-759-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant