Provider Demographics
NPI:1730496043
Name:BRONNER, CHARLES ANDREW (OTR)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ANDREW
Last Name:BRONNER
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6145
Mailing Address - Country:US
Mailing Address - Phone:315-457-7948
Mailing Address - Fax:
Practice Address - Street 1:106 VALLEY RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6145
Practice Address - Country:US
Practice Address - Phone:315-457-7948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005650225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist