Provider Demographics
NPI:1730540717
Name:STREET, BONITA (PTA)
Entity type:Individual
Prefix:MS
First Name:BONITA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 SAWNEY CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29130-7104
Mailing Address - Country:US
Mailing Address - Phone:803-237-5733
Mailing Address - Fax:
Practice Address - Street 1:198 SAWNEY CREEK CIR
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:SC
Practice Address - Zip Code:29130-7104
Practice Address - Country:US
Practice Address - Phone:803-237-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3474373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist