Provider Demographics
NPI:1902077118
Name:CHARBONNEAU, BRAD G (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:G
Last Name:CHARBONNEAU
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2162 CALCUTTA RD
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-8632
Mailing Address - Country:US
Mailing Address - Phone:603-769-1818
Mailing Address - Fax:
Practice Address - Street 1:1026 ALBEE FARM RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-6213
Practice Address - Country:US
Practice Address - Phone:603-769-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12224225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist