MEDICARE: MRS. BRIDGET CONQUEST

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	106E00000X	Assistant Behavior Analyst	0-24-15068	FL
2	106S00000X	Behavior Technician		FL
3	222Q00000X	Developmental Therapist		FL
4	222Q00000X	Developmental Therapist
5	103K00000X	Behavior Analyst	1-24-76645	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164054854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRIDGET CONQUEST

Provider Business Mailing Address
First Line	:	356 WESTERN RD
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-8969
Country	:	US
Telephone Number	:	908-965-5220
Fax Number	:

Provider Business Practice Location Address
First Line	:	4647 CLYDE MORRIS BLVD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3000
Country	:	US
Telephone Number	:	386-767-3752
Fax Number	:

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

Provider Enumeration Date	:	02/10/2020
Last Update Date	:	10/18/2024

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