Healthcare Provider Details

I. General information

NPI: 1023764701
Provider Name (Legal Business Name): BRIDGES SPEECH LANGUAGE PATHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 GOLD ST APT 12A
BROOKLYN NY
11201-1280
US

IV. Provider business mailing address

309 GOLD ST APT 12A
BROOKLYN NY
11201-1280
US

V. Phone/Fax

Practice location:
  • Phone: 405-593-0414
  • Fax:
Mailing address:
  • Phone: 405-593-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: CAROL GIACO
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: CCC-SLP
Phone: 405-593-0414