Provider Demographics
NPI:1073854568
Name:BRONNER, MICHELLE C (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:BRONNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17595 HARVARD AVE STE C2230
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-8516
Mailing Address - Country:US
Mailing Address - Phone:949-394-6587
Mailing Address - Fax:
Practice Address - Street 1:65 LONG MDW
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-2825
Practice Address - Country:US
Practice Address - Phone:949-394-6587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 9591225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist