=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720476336
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEANIE LYNETTE BRIDGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2015
-----------------------------------------------------
Last Update Date | 04/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 518 28 RD STE A101 A101
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81501-6557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-778-2473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 518 28 RD A101
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81501-6556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-778-2473
-----------------------------------------------------
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 | 0015059
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------