=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104394287
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIDGETTE IRENE CANAL LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2018
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4312 N FLORIDA AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33603-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-421-3583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5408 N SEMINOLE AVE APT A
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33604-7031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-415-0734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH20565
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------