Healthcare Provider Details

I. General information

NPI: 1841037686
Provider Name (Legal Business Name): BRIDGETT MUCKLE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6754 HIGHWAY 72 W
COLBERT GA
30628-2407
US

IV. Provider business mailing address

460 BARNETT SHOALS RD APT E6
ATHENS GA
30605-7608
US

V. Phone/Fax

Practice location:
  • Phone: 706-788-3234
  • Fax:
Mailing address:
  • Phone: 706-410-6077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009110
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: