Provider Demographics
NPI:1326655804
Name:PHELAN, BRIDIE ANN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:BRIDIE
Middle Name:ANN
Last Name:PHELAN
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SHALE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-7685
Mailing Address - Country:US
Mailing Address - Phone:917-618-9356
Mailing Address - Fax:
Practice Address - Street 1:234 E 237TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-2007
Practice Address - Country:US
Practice Address - Phone:347-449-7719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01140800225700000X
NY9449225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist