Provider Demographics
NPI:1679178131
Name:BONNER, ASHLEY TAYLOR (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:ASHLEY
Middle Name:TAYLOR
Last Name:BONNER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12505 PATNOE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9244
Mailing Address - Country:US
Mailing Address - Phone:708-203-4930
Mailing Address - Fax:
Practice Address - Street 1:10 S 9TH ST STE 4
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2631
Practice Address - Country:US
Practice Address - Phone:317-204-3736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003501A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant