Basic Information
| Provider Information | |||||||||
| NPI: | 1679748438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONESKE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | COTA | ||||||||
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| OtherLastName: | ROGERS | ||||||||
| OtherFirstName: | AMANDA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6578 IRON BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544118409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154700586 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 333 PINE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2008 | ||||||||
| LastUpdateDate: | 03/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 2043-027 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.