=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861817496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIDIANE BRIDGES LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2014
-----------------------------------------------------
Last Update Date | 11/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15063 GAINES MILL CIR
-----------------------------------------------------
City | HAYMARKET
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20169-2592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-754-3914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15063 GAINES MILL CIR
-----------------------------------------------------
City | HAYMARKET
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20169-2592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-825-7866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 9604
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------