Provider Demographics
NPI:1265764229
Name:WILLIS, BRONWYN K (OTR/L)
Entity type:Individual
Prefix:
First Name:BRONWYN
Middle Name:K
Last Name:WILLIS
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 1:1201 ATRISCO DR SW
Mailing Address - Street 2:ATRISCO ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NEW MEXICO
Mailing Address - Zip Code:87105
Mailing Address - Country:UM
Mailing Address - Phone:505-877-2772
Mailing Address - Fax:
Practice Address - Street 1:1201 ATRISCO DR SW
Practice Address - Street 2:ATRISCO ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3550
Practice Address - Country:US
Practice Address - Phone:505-877-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM029225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNONE ASSIGNEDMedicaid