MEDICARE: BRIDGET MODICA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1467584458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIDGET MODICA

Provider Business Mailing Address
First Line	:	8681 WESLEYAN DR
Second Line	:	APT. 6-19
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5260
Country	:	US
Telephone Number	:	239-728-7976
Fax Number	:	239-236-3597

Provider Business Practice Location Address
First Line	:	8681 WESLEYAN DR
Second Line	:	APT. 6-19
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5260
Country	:	US
Telephone Number	:	239-728-7976
Fax Number	:	239-236-3597

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	07/08/2007

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Directions to “ BRIDGET MODICA ” Practice Location

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