Healthcare Provider Details

I. General information

NPI: 1265764229
Provider Name (Legal Business Name): BRONWYN K WILLIS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ATRISCO DR SW ATRISCO ES
ALBUQUERQUE NM
87105-3550
US

IV. Provider business mailing address

1201 ATRISCO DR SW ATRISCO ES
ALBUQUERQUE NEW MEXICO
87105
UM

V. Phone/Fax

Practice location:
  • Phone: 505-877-2772
  • Fax:
Mailing address:
  • Phone: 505-877-2772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number029
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: