Healthcare Provider Details

I. General information

NPI: 1558291898
Provider Name (Legal Business Name): BRIDGETTE NADINE MCCLURE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13775 E TAYLOR ST
BENTON IL
62812-5924
US

IV. Provider business mailing address

13775 E TAYLOR ST
BENTON IL
62812-5924
US

V. Phone/Fax

Practice location:
  • Phone: 618-927-7573
  • Fax:
Mailing address:
  • Phone: 618-927-7573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149031121
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: