Healthcare Provider Details

I. General information

NPI: 1053136531
Provider Name (Legal Business Name): BRIDGET CUP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 E BLOOMINGTON FWY STE 142
BLOOMINGTON MN
55420-3485
US

IV. Provider business mailing address

9001 E BLOOMINGTON FWY STE 142
BLOOMINGTON MN
55420-3485
US

V. Phone/Fax

Practice location:
  • Phone: 612-877-2277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4537
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: