Provider Demographics
NPI:1134846405
Name:BRONNER, TESSA JO
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:JO
Last Name:BRONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2933
Mailing Address - Country:US
Mailing Address - Phone:989-854-8334
Mailing Address - Fax:
Practice Address - Street 1:1524 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2933
Practice Address - Country:US
Practice Address - Phone:989-854-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB656789420760106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB656789420760Medicaid