Healthcare Provider Details

I. General information

NPI: 1154898351
Provider Name (Legal Business Name): BRIDGETTE MARIE EASTMAN MS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4224
US

IV. Provider business mailing address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4224
US

V. Phone/Fax

Practice location:
  • Phone: 218-331-4866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC01935
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC09135
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: