Provider Demographics
NPI:1538926340
Name:BONNER, SOPHIE (LMT)
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SOPHIE
Other - Middle Name:
Other - Last Name:TULACZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1910 S HIGHLAND AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6129
Mailing Address - Country:US
Mailing Address - Phone:630-776-3043
Mailing Address - Fax:
Practice Address - Street 1:1910 S HIGHLAND AVE STE 260
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6129
Practice Address - Country:US
Practice Address - Phone:630-776-3043
Practice Address - Fax:630-929-1390
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227000263225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist