Provider Demographics
NPI:1437205762
Name:BRIDGE, CAROLYN (MS, CCC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:BRIDGE
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:MS
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:DAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5422 16TH LN NE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-1754
Mailing Address - Country:US
Mailing Address - Phone:813-787-2341
Mailing Address - Fax:
Practice Address - Street 1:5422 16TH LN NE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-1754
Practice Address - Country:US
Practice Address - Phone:813-787-2341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8835235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890964400Medicaid
FL812013700Medicaid
FLFA679ZMedicare PIN