=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033916556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIDGETT CONKLE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3718 RIDGE MILL DR
-----------------------------------------------------
City | HILLIARD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43026-9231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 380-400-4673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3718 RIDGE MILL DR
-----------------------------------------------------
City | HILLIARD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43026-9231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 380-400-4673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CDCA.185099
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------