MEDICARE: BRIDGETTE MICHELLE KING LPC

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	LPC005817	GA

General Provider Information

NPI Number	:	1689983629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIDGETTE MICHELLE KING LPC

Provider Business Mailing Address
First Line	:	6300 MILGEN RD
Second Line	:	APARTMENT 1364
City	:	COLUMBUS
State	:	GA
Zip	:	31907-5889
Country	:	US
Telephone Number	:	678-340-5672
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 MILGEN RD
Second Line	:	APARTMENT 1364
City	:	COLUMBUS
State	:	GA
Zip	:	31907-5889
Country	:	US
Telephone Number	:	678-340-5672
Fax Number	:

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

Provider Enumeration Date	:	09/24/2010
Last Update Date	:	09/24/2010

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