Provider Demographics
NPI:1114590890
Name:BRIDGES, DALLAS NICOLE
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:NICOLE
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2818 CLAY TURNER RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33566-7607
Mailing Address - Country:US
Mailing Address - Phone:813-716-9762
Mailing Address - Fax:
Practice Address - Street 1:1818 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1812
Practice Address - Country:US
Practice Address - Phone:781-923-0900
Practice Address - Fax:781-616-3306
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician