MEDICARE: MS. TANDRA RENEE BRIDGES LPCIT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	835-226	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	835-226	OTHER	WI	PROFESSIONAL COUNSELOR TRAINING LIC

General Provider Information

NPI Number	:	1033456553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TANDRA RENEE BRIDGES LPCIT

Provider Business Mailing Address
First Line	:	2941 N 44TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1710
Country	:	US
Telephone Number	:	414-313-7656
Fax Number	:

Provider Business Practice Location Address
First Line	:	2941 N 44TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1710
Country	:	US
Telephone Number	:	414-313-7656
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2013
Last Update Date	:	01/04/2013

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