Healthcare Provider Details

I. General information

NPI: 1720621238
Provider Name (Legal Business Name): BRIDGET GOSIEWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CAREW ST
SPRINGFIELD MA
01104-2389
US

IV. Provider business mailing address

154 CAREW ST
SPRINGFIELD MA
01104-3405
US

V. Phone/Fax

Practice location:
  • Phone: 413-452-6760
  • Fax:
Mailing address:
  • Phone: 413-386-6080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4908-NU-NU
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: