Healthcare Provider Details

I. General information

NPI: 1063816320
Provider Name (Legal Business Name): BRIDGET MARY HORMBERG OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

567 N AND SOUTH RD APT C
SAINT LOUIS MO
63130-3939
US

IV. Provider business mailing address

567 N AND SOUTH RD APT C
SAINT LOUIS MO
63130-3939
US

V. Phone/Fax

Practice location:
  • Phone: 314-650-9288
  • Fax:
Mailing address:
  • Phone: 314-650-9288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2014027319
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: