Healthcare Provider Details

I. General information

NPI: 1740572965
Provider Name (Legal Business Name): BRIDGETTE J PETEET PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRIDGETTE J MITCHELL PHD

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 ANDERSON ST
LOMA LINDA CA
92350-1729
US

IV. Provider business mailing address

11130 ANDERSON ST
LOMA LINDA CA
92350-1729
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-8717
  • Fax:
Mailing address:
  • Phone: 909-558-8717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number31726
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6300
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: