Basic Information
| Provider Information | |||||||||
| NPI: | 1689624314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONROE | ||||||||
| FirstName: | BAMBI | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARMON | ||||||||
| OtherFirstName: | BAMBI | ||||||||
| OtherMiddleName: | RENAE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 809 FARSON STREET | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BELPRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457141067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404231500 | ||||||||
| FaxNumber: | 7404231504 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 FARSON STREET | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BELPRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457141067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404231500 | ||||||||
| FaxNumber: | 7404231504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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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 | 225100000X | 001347 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2197457 | 05 | OH | MEDICAID | 0157773000 | 05 | WV | MEDICAID |