=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659625937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS COMPANY VII
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2012
-----------------------------------------------------
Last Update Date | 03/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1819 W AUSTIN BLVD STE C
-----------------------------------------------------
City | NEVADA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64772-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-283-6151
-----------------------------------------------------
Fax | 417-283-6152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1819 W AUSTIN BLVD STE C
-----------------------------------------------------
City | NEVADA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64772-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-283-6151
-----------------------------------------------------
Fax | 417-283-6152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. PATRICIA E BRIDGEWATER
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 417-549-0572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1999140492
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------