Healthcare Provider Details

I. General information

NPI: 1346365103
Provider Name (Legal Business Name): MARC LEE CHARBONNEAU PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 99, UNIT 5024, MISAWA AB
APO AP
96319
US

IV. Provider business mailing address

PO BOX 80217
PHOENIX AZ
85060-0217
US

V. Phone/Fax

Practice location:
  • Phone: 315-226-6111
  • Fax:
Mailing address:
  • Phone: 602-385-2115
  • Fax: 480-418-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8226
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: