Provider Demographics
NPI:1780159855
Name:BRONNENBERG, MARK (MSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BRONNENBERG
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1567
Mailing Address - Country:US
Mailing Address - Phone:510-703-3392
Mailing Address - Fax:
Practice Address - Street 1:6239 COLLEGE AVE STE 304
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1384
Practice Address - Country:US
Practice Address - Phone:510-703-3392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS164971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical