Provider Demographics
NPI:1255416020
Name:BRONSON, MARY JO (PT)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:BRONSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 GARDEN TER N
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-2158
Mailing Address - Country:US
Mailing Address - Phone:732-690-7089
Mailing Address - Fax:732-602-0046
Practice Address - Street 1:585 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1104
Practice Address - Country:US
Practice Address - Phone:732-636-5151
Practice Address - Fax:732-602-0046
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00387600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ31-6649Medicare ID - Type UnspecifiedFACILITY MEDICARE NUMBER