=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952081200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGE SPEECH THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2023
-----------------------------------------------------
Last Update Date | 07/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 4TH ST N STE B
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33703-4735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-201-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5422 16TH LN NE
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33703-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-787-2341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | CAROLYN BRIDGE
-----------------------------------------------------
Credential | M.S., CCC-SLP
-----------------------------------------------------
Telephone | 813-787-2341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------