=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346365103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC LEE CHARBONNEAU PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BUILDING 99, UNIT 5024, MISAWA AB
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-226-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 80217
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85060-0217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-385-2115
-----------------------------------------------------
Fax | 480-418-3323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 8226
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------