Healthcare Provider Details

I. General information

NPI: 1417548793
Provider Name (Legal Business Name): LINDA MARIE BRIDGES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6763 PAGE AVE
SAINT LOUIS MO
63133-1635
US

IV. Provider business mailing address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-1720
  • Fax:
Mailing address:
  • Phone: 314-206-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number2007032949
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: