Provider Demographics
NPI:1871100792
Name:BONILLA, ALIZA PABUA (PT)
Entity type:Individual
Prefix:MS
First Name:ALIZA
Middle Name:PABUA
Last Name:BONILLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-5423
Mailing Address - Country:US
Mailing Address - Phone:929-334-7856
Mailing Address - Fax:
Practice Address - Street 1:165 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-7105
Practice Address - Country:US
Practice Address - Phone:718-253-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044527-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist