Provider Demographics
NPI:1215355987
Name:BRIDGEWATER, KRYSTAL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:BRIDGEWATER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 12TH ST NE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120-0474
Mailing Address - Country:US
Mailing Address - Phone:239-216-1475
Mailing Address - Fax:
Practice Address - Street 1:4521 12TH ST NE
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34120-0474
Practice Address - Country:US
Practice Address - Phone:239-216-1475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9976225100000X
TX1241350225100000X
FLPT29086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist