Provider Demographics
NPI:1023365806
Name:EINWICH-BRIDOUX, TRACY SUE (BA)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:SUE
Last Name:EINWICH-BRIDOUX
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N BEACH ST
Mailing Address - Street 2:DAYTONA BEACH, FL 32114
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3314
Mailing Address - Country:US
Mailing Address - Phone:386-341-6789
Mailing Address - Fax:386-868-2569
Practice Address - Street 1:160 N BEACH ST
Practice Address - Street 2:DAYTONA BEACH, FL 32114
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3314
Practice Address - Country:US
Practice Address - Phone:386-944-4707
Practice Address - Fax:386-868-2569
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
E521817675960OtherFLORIDA DRIVERS LICENSE NUMBER