Basic Information
Provider Information | |||||||||
NPI: | 1770897159 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONASSO | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | ASHLEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MOT, OTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6000 HAMPTON CTR | ||||||||
Address2: | STE B | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265051748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045991500 | ||||||||
FaxNumber: | 3045997800 | ||||||||
Practice Location | |||||||||
Address1: | 140 CARRIAGE CLUB DR | ||||||||
Address2: |   | ||||||||
City: | MOORESVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 281179284 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046581200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2010 | ||||||||
LastUpdateDate: | 07/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1489 | WV | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225X00000X | 8676 | NC | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 4005078000 | 05 | WV |   | MEDICAID |