Provider Demographics
NPI:1770897159
Name:BONASSO, LAUREN ASHLEY (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:BONASSO
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 HAMPTON CTR
Mailing Address - Street 2:STE B
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1748
Mailing Address - Country:US
Mailing Address - Phone:304-599-1500
Mailing Address - Fax:304-599-7800
Practice Address - Street 1:140 CARRIAGE CLUB DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9284
Practice Address - Country:US
Practice Address - Phone:704-658-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1489225X00000X
NC8676225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4005078000Medicaid
WV516524Medicare Oscar/Certification