Provider Demographics
NPI:1063816320
Name:HORMBERG, BRIDGET MARY (OT)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:MARY
Last Name:HORMBERG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 N AND SOUTH RD APT C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3939
Mailing Address - Country:US
Mailing Address - Phone:314-650-9288
Mailing Address - Fax:
Practice Address - Street 1:567 N AND SOUTH RD APT C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-3939
Practice Address - Country:US
Practice Address - Phone:314-650-9288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027319225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics