Basic Information
| Provider Information | |||||||||
| NPI: | 1235312547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 GORHAM RD | ||||||||
| Address2: | FLOOR 1 | ||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021552272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813960607 | ||||||||
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| Practice Location | |||||||||
| Address1: | 61 MEDFORD ST | ||||||||
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| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021433421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176293919 | ||||||||
| FaxNumber: | 6176294644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2007 | ||||||||
| LastUpdateDate: | 12/10/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 2246 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No ID Information.